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TRANSACTIONS 


OP 


NATIONAL  CONFERENCE 

III 


ON 


Pellagra 

Held  Under  Auspices  of 

South  Carolina  State  Board 
of  Health 

at  State  Hospital  for  the  Insane,  Columbia,  S.  C. 
November  3  and  4,  1909 


COLUMBIA,  S.  C, 

THE   STATE   CO.,  PRINTERS, 

1910. 


RCU£ 


/M 


Called  Meeting  of  Executive  Committee  of  the  State 

Board  of  Health  to  Conduct  National 

Conference  on  Pellagra. 


Columbia,  S.  C,  Nov.  3,  1909. 
The  First  National  Conference  on  Pellagra  was  held  under  the 
auspices  of  the  South  Carolina  State  Board  of  Health  at  the  State 
Hospital  for  the  Insane,   Columbia,   South  Carolina,   November  3 
and  4,  1909. 

November  Third — First  Session. 

The  conference  met  at  2  :30  p.  m.,  and  in  the  absence  of  the  Chair- 
man, Dr.  Wilson,  was  called  to  order  by  Dr.  C.  F.  Williams,  Secre- 
tary of  the  State  Board  of  Health,  who  introduced  Governor  Ansel 
to  welcome  those  who  had  assembled  to  take  part  in  the  conference. 

Governor  Ansel  was  warmly  received  and  his  address  heartily 
applauded. 

The  address  of  welcome  was  responded  to,  on  behalf  of  the  visit- 
ing delegates,  by  Dr.  Wm.  C.  Woodward,  Commissioner  of  Health, 
Washington,  D.  C,  at  the  conclusion  of  which  Dr.  J.  W.  Babcock 
said :  Governor  Ansel  has  referred  to  me  as  having  been  the  dis- 
coverer of  pellagra  in  this  country.  Pellagra  was  discovered  in  this 
country  many  years  before  I  made  my  observations  upon  it.  It  was 
discussed  at  a  meeting  of  the  asylum  superintendents  in  Washington 
as  far  back  as  1864.  It  was  observed  in  Brooklyn,  New  York,  by 
Dr.  Sherwell,  an  eminent  dermatologist.  It  was  observed  twenty-two 
years  ago,  so  I  have  been  informed,  by  Dr.  Bass,  of  New  Orleans, 
by  Doctor  Bemis  of  that  city.  It  has  probably  prevailed  in  this 
institution  for  a  generation.  Furthermore,  Dr.  Harris,  of  Georgia, 
made  a  notable  observation  upon  pellagra  in  1902,  and  the  hero  of 
our  modern  civilization,  the  country  doctor,  observed  it  several  years 
ago,  notably  Dr.  McConnell,  of  Chester,  S.  C,  also  Dr.  Wright,  of 
Lincolnton,  N.  C,  and  Dr.  Bellamy,  of  Wilmington.  The  disease 
was  observed  in  the  Alabama  Asylum  for  Colored  Insane  before 
observations  had  been  made  in  the  South  Carolina  Hospital,  so  that 
if  you  and  the  Governor  will  pardon  me,  I  do  not  wish  to  be  placed 
in  the  false  position  of  making  any  claims  as  to  having  discovered  or 
made  any  early  observations  upon  pellagra,  because  such  is  not  the 


case,  and  credit  is  due  to  all  of  the  gentlemen  whose  names  I  have 
mentioned,  and  perhaps  there  are  others.  I  am  sure  everyone  of  us 
is  interested  in  bringing  out  the  whole  truth  with  regard  to  the 
pellagra  problem,  and  we  are  all  here  in  the  interest  of  truth  and  jus- 
tice to  those  gentlemen  who  are  entitled  to  priority  long  before  any 
observations  that  may  have  been  made  of  this  disease  in  this  institu- 
tion. 

At  the  conclusion  of  Dr.  Babcock's  remarks  the  reading  of  papers 
was  begun. 

Dr.  F.  M.  Sandwith,  F.  R.  C.  P.,  Gresham  Professor  of  Physic, 
London,  England,  contributed  a  paper  entitled  "Introductory 
Remarks",  which  was  read  by  Doctor  Babcock  in  the  absence  of  the 
author. 

Assistant  Surgeon  General  Kerr,  U.  S.  P.  H.  and  M.-H.  Service, 
Washington,  D.  C.,  read  a  paper  entitled  "Pellagra :  As  a  National 
Public  Health  Problem." 

Mr.  E.  J.  Watson,  Commissioner  Department  of  Agriculture, 
Commerce  and  Industries,  Columbia,  S.  C,  read  a  paper  entitled 
"Economic  Factors  of  the  Pellagra  Problem  in  South  Carolina." 

Passed  Assistant  Surgeon  C.  H.  Lavinder,  U.  S.  P.  H.  and  M.-H. 
Service,  Washington,  D.  C,  read  a  paper  "Notes  on  the  Hema- 
tology of  Pellagra." 

These  papers  were  discussed  by  Drs.  R.  N.  Greene,  Chattahoochee, 
Florida ;  C.  C.  Bass  of  New  Orleans,  Louisiana ;  Walter  H.  Buhlig, 
Chicago,  Illinois,  and  Louis  LeRoy,  Memphis,  Tennessee. 

Dr.  George  A.  Zeller,  Superintendent  State  Hospital,  Peoria, 
Illinois,  read  a  paper  entitled  "Pellagra :  Its  Recognition  in  Illinois 
and  the  Means  Taken  to  Control  It." 

Dr.  J.  F.  Siler  and  Dr.  H.  J.  Nichols,  Captains  Medical  Corps, 
United  States  Army,  read  a  joint  paper  entitled  "Aspects  of  the 
Pellagra  Situation  in  Illinois." 

These  papers  were  discussed  by  Drs.  C.  L.  Minor,  Asheville,  N. 
C. ;  C.  F.  Williams,  Columbia,  S.  C. ;  L.  J.  Pollock,  Dunning,  111. ; 
C.  H.  Lavinder,  Washington,  D.  C. ;  J.  W.  Mobley,  Milledgeville, 
Ga. ;  J.  W.  Babcock,  Columbia,  S.  C. ;  Julius  C.  Sosnowski,  Charles- 
ton, S.  C;  M.  B.  Young,  Rock  Hill,  S.  C. ;  H.  E.  Menage,  New 
Orleans,  La. ;  John  W.  Thomas,  Pineville,  La. ;  Geo.  A.  Zeller, 
Peoria,  111.,  and  I.  W.  Faison,  Charlotte,  N.  C. 

Dr.  Isadore  Dyer  of  New  Orleans,  La.,  contributed  a  paper  enti- 
tled "Some  Differential   Points   in  the  Skin  Lesions  of  Pellagra. 


Report  of  One  Case  With  Removal  of  Symptoms,"  which  was  read 
by  Dr.  Menage  in  the  absence  of  the  author. 

At  this  juncture  the  chairman  announced  the  chairman  of  the 
following  conference  committees :  The  Committee  on  Publication, 
Dr.  C.  F.  Williams ;  the  Committee  on  Permanent  Organization, 
Dr.  Geo.  A.  Zeller;  Committee  on  Statistics,  Asst.  Surgeon  General 
Kerr;  Committee  on  Resolutions,  Dr.  J.  Howell  Way;  Committee 
on  Ways  and  Means,  Dr.  J.  M.  Buchanan. 

On  motion,  these  nominations  were  confirmed  by  the  conference, 
and  the  chairman  of  each  committee  empowered  to  select  four  addi- 
tional members. 

On  motion  the  conference  then  adjourned  until  8:30  p.  m. 

First  Day — Evening  Session. 

The  conference  re-assembled  at  8:30  p.  m.,  and  was  called  to 
order  by  Dr.  W.  J.  Burdell,  member  of  the  South  Carolina  State 
Board  of  Health,  Lugoff,  South  Carolina. 

Dr.  Geo.  F.  Gaumer,  Yucatan,  Mexico,  contributed  a  paper  enti- 
tled ''Pellagra  in  Yucatan." 

Dr.  C.  J.  Manning,  M.  R.  C.  S.,  England,  L.  R.  C.  P.  Ed.,  Medi- 
cal Superintendent  Lunatic  Asylum,  contributed  a  paper  on  "Psilosis 
Pigmentosa  in  Barbadoes",  which  was  read  by  Dr.  White  in  the 
absence  of  the  author. 

A  contribution  entitled  "Pellagra  in  Jamaica"  by  Dr.  D,  J. 
Williams,  Medical  Sviperintendent,  The  Asylum,  Kingston,  Jamaica, 
W.  I.,  was  read. 

Dr.  A.  Marie,  Paris,  France,  contributed  a  paper  entitled  "Pella- 
grous Insanity  Among  the  Arabs  in  Egypt",  which  was  read  by 
Dr.  Mason  in  the  absence  of  the  author. 

Dr.  John  Warnock,  Medical  Director,  Government  Hospital  for 
the  Insane,  Abbassia,  Cairo,  Egypt,  contributed  a  paper  on  "Pellagra 
in  Egypt." 

A  paper  entitled  "A  Note  on  Pellagra  in  Egypt",  by  R.  G.  White, 
M.  D.,  Director,  Serum  Institute,  Abbassia,  Cairo,  Egypt,  was  read 
by  Dr.  Reid  Hunt. 

On  motion  the  conference  then  adjourned  until  Thursday,  10:00 
a.  m. 

November  Fourth — Second  Day  Morning  Session. 

The  conference  met  at  10  :oo  a.  m.,  and  was  called  to  order  by  Dr. 
Robert  Wilson,  President  of  the  State  Board  of  Health  of  South 
Carolina. 


As  there  were  so  many  papers  on  the  program  to  be  read,  Dr. 
Wm.  C.  White  moved  that  the  reading  of  each  paper  be  restricted 
to  fifteen  minutes  and  that  the  time  allowed  to  any  person  for  dis- 
cussion be  limited  to  five  minutes. 

The  motion  was  duly  seconded  and  carried. 

Dr.  E.  B.  Saunders,  State  Hospital,  Columbia,  S.  C,  read  a  paper 
entitled  "The  Surgical,  Gynecological  and  Obstetric  Aspects  of  Pella- 
gra." 

Dr.  C.  L.  Minor  of  Asheville,  N.  C,  moved  that  the  cases  of 
pellagra  be  now  exhibited  before  the  rest  of  the  program  is  pro- 
ceeded with. 

Seconded  and  carried. 

Several  clinical  cases  were  then  presented  and  demonstrated  by 
Drs.  J.  J.  Watson,  J.  W.  Babcock,  H.  E.  McConncll  and  others. 

Dr.  J.  W.  Mobley  of  Milledgeville,  Ga.,  read  a  paper  entitled 
"Pellagra :   Its  Relation  to  Insanity  and  Certain  Nervous  Diseases." 

This  paper  was  discussed  by  Drs.  W.  H.  Dial,  Laurens,  S.  C. ; 
J.  W.  Babcock,  Columbia,  S.  C. ;  M.  B.  Young,  Rock  Hill,  S.  C, 
and  B.  R.  Tucker,  Richmond,  Va. 

Dr.  J.  H.  Taylor  of  Columbia,  S.  C,  read  a  paper  entitled  "The 
Question  of  Etiology  of  Pellagra." 

This  paper  was  discussed  by  Drs.  William  Allen,  Charlotte,  N.  C. ; 
Walter  H.  Buhlig,  Chicago,  111. ;  H.  J,  Nichols,  United  States  Army ; 
J.  J.  Watson,  Columbia,  S.  C. ;  W.  H.  Dial,  Laurens,  S.  C. ;  Hiram 
Byrd,  Jacksonville,  Fla.';  J.  D.  Jones,  Sweetwater,  Ala.;  Louis  Leroy, 
Memphis,  Tenn. 

Mr.  J.  Swinton  Whaley,  Edisto  Island,  S.  C,  contributed  a  paper 
entitled  "Personal  Experience  With  Damaged  Corn",  after  which 
Dr.  Taylor  was  called  upon  to  close  the  discussion. 

Dr.  C.  C.  Bass  of  New  Orleans,  La.,  read  a  paper  entitled  "Com- 
plement Fixation  in  Pellagra :  Further  Observations." 

Dr.  Howard  Fox  of  New  York  City  read  a  paper  entitled  "The 
Wassermann  Reaction  (Noguchi  Modification)  in  Pellagra." 

Drs.  H.  P.  Cole  and  G.  J.  Winthrop  of  Mobile,  Ala.,  contributed 
a  joint  paper  entitled  "Transfusion  of  Blood  in  Pellagra."  This 
paper  was  read  by  Doctor  Mason,  Bacteriologist  of  the  Alabama 
State  Board  of  Health,  in  the  absence  of  the  authors. 

The  paper  was  discussed  by  Drs.  J.  H.  Taylor,  Columbia,  S.  C. ; 
C.  C.  Bass,  New  Orleans,  La. ;  M.  B.  Young,  Rock  Hill,  S.  C,  and 
the  discussion  closed  by  Dr.  Fox. 


Dr.  J.  M.  King  of  Nashville,  Tenn.,  contributed  a  paper  entitled 
"Report  on  Pellagra  in  Nashville,  Tennessee",  vi^hich  was  read  by 
Dr.  Louis  Leroy  in  the  absence  of  the  author. 

This  paper  was  discussed  by  Dr.  C.  H.  Lavinder  of  Washington, 
D.  C,  and  Dr.  W.  E.  Hibbert,  Nashville,  and  the  discussion  closed 
by  Dr.  Leroy. 

The  chairman  announced  the  following  additional  members  of 
the  Committee  on  Resolutions :  Drs.  Charles  L.  Minor,  J.  T.  McAn- 
ally  and  C.  C.  Bass. 

The  additional  members  of  Committee  on  Permanent  Organiza- 
tion: Drs.  Louis  Leroy,  E.  M.  Mason,  W.  O.  Nisbet  and  B.  L. 
Eiker. 

Dr.  H.  E.  McConnell  of  Chester,  S.  C,  read  a  paper  entitled 
"Facts  and  Theories  of  Pellagra." 

The  paper  was  discuseed  by  Dr.  M.  B.  Young,  Rock  Hill,  S.  C, 
and  in  closing  by  the  author  of  the  paper,  after  which  the  conference 
on  motion  adjourned  until  2 :30  p.  m. 

Second  Day — Afternoon  Session. 

The  conference  re-assembled  at  3  :oo  p.  m.,  with  Dr.  Wilson  in 
the  chair. 

Dr.  Wm.  Allen  of  Charlotte,  N.  C,  read  a  paper  entitled  "Ameba 
in  Stools  in  Pellagra." 

Discussed  by  Dr.  H.  J.  Nichols,  and  in  closing  by  the  author 
of  the  paper. 

Dr.  J.  J.  Watson  of  Columbia,  S.  C,  followed  with  a  paper  enti- 
tled "Symptomatology  of  Pellagra." 

This  paper  was  discussed  by  Dr.  C.  L.  Minor,  Asheville,  N.  C, 
and  in  closing  by  Dr.  Watson. 

Dr.  T.  W.  L.  Bailey,  Clinton,  S.  C,  read  a  paper  entitled  "Per- 
sonal Observations  on  Pellagra." 

Dr.  B.  L.  Eiker  of  Leon,  la.,  presented  the  following  report  of 
the  Committee  on  Permanent  Organization : 

Mr.  President :  Your  Committee  on  Permanent  Organization  begs 
leave  to  submit  the  following  report:  We  recommend  the  forma- 
tion of  a  National  Association  for  the  Study  of  Pellagra,  and  we 
further  recommend  that  the  next  congress  be  held  at  Peoria,  Illinois, 
in  the  month  of  June,  1910.  Recognizing  the  distinguished  services 
of  Dr.  J.  W.  Babcock  of  Columbia,  S.  C,  in  organizing  and  promot- 
ing this  movement,  we  respectfully  place  him  in  nomination  for 
president  of  this  association.    For  first  vice-president  we  recommend 


8 

Dr.  Wm.  A.  White  of  the  Government  Hospital,  and  we  further 
recommend  that  one  vice-president  be  selected  from  each  State  in 
the  Union  interested  in  the  study  of  this  disease,  said  official  to  be 
appointed  by  the  Secretary  of  the  State  Board  of  Health  of  each 
State.  We  further  recommend  that  a  permanent  secretary  and  treas- 
urer be  elected  by  this  association. 

After  reading  the  report  Dr.  Eiker  moved  its  adoption,  which  was 
seconded  by  Dr.  Louis  Leroy  and  carried. 

As  Peoria,  Illinois,  was  selected  as  the  place  for  the  next  meeting, 
Dr.  Louis  Leroy  nominated  for  Secretary-Treasurer  Dr.  Geo.  A.  Zel- 
ler,  which  motion  was  seconded  by  Dr.  J.  J.  Watson  and  carried. 

On  motion  of  Dr.  C.  L.  Minor  the  Committee  on  Permanent 
Organization  was  instructed  to  formulate  a  Constitution  and  By- 
Laws  and  present  same  at  a  subsequent  session  of  the  conference. 

The  Committee  on  Resolutions  presented  the  following  report: 

Report  of  the  Committee  on  Resolutions. 

Dr.  J.  Howell  Way  of  Waynesville,  N.  C,  a  member  of  the  North 
Carolina  State  Board  of  Health,  for  the  Committee  on  Resolutions 
submitted  the  following: 

1.  Resolved,  That  we  appreciate  most  highly  the  splendid  work 
performed  by  Dr.  C.  F.  Williams,  the  efficient  Secretary  of  the 
South  Carolina  State  Board  of  Health,  in  organizing  and  success- 
fully promoting  this  conference  for  the  study  of  pellagra. 

2.  Resolved,  That  we  tender  our  sincere  thanks  to  Dr.  J.  W.  Bab- 
cock,  whom  we  justly  recognize  as  the  father  of  the  movement  for 
the  study  and  control  of  pellagra  in  America,  for  his  valuable  labors 
and  his  many  courtesies  to  this  body  during  our  session. 

3.  Resolved,  That  the  purposes  for  which  this  conference  was 
called  can  best  be  furthered  by  its  formal  organization  into  a  per- 
manent association  of  national  scope,  and  that  the  Committee  on 
Permanent  Organization  be  instructed  to  report  at  this  session. 

4.  Resolved,  That  this  conference  recognizes  the  widespread 
existence  of  pellagra  in  the  United  States  and  urges  upon  the 
National  Government  the  necessity  of  bringing  its  powerful  resources 
to  bear  upon  the  vital  question  of  its  cause,  prevention  and  control. 

5.  Resolved,  That  while  sound  corn  is  in  no  way  connected  with 
pellagra,  evidences  of  the  relation  between  the  use  of  spoiled  corn 
and  the  prevalence  of  pellagra  seem  so  apparent  that  we  advise 
continued  and  systematic  study  of  the  subject,  and,  in  the  meantime. 


we  commend  to  corn  growers  the  great  importance  of  fully  maturing 
corn  upon  the  stalk  before  cutting  the  same. 

6.  Resolved,  That  the  work  of  this  conference  be  brought  to  the 
attention  of  the  various  State  and  Territorial  Boards  of  Health  and 
they  severally  be  urged  to  specially  investigate  the  disease,  particu- 
larly as  regards  its  prevalence,  and  that  they  also  see  that  the 
proper  inspection  of  corn  products  sold  in  the  various  States  be 
had. 

7.  Resolved,  That  the  Secretary  be  instructed  to  convey  to  the 
family  of  the  late  Cesare  Lombroso  our  sympathy  in  their  loss  and 
our  appreciation  of  his  great  work  in  the  study  of  pellagra. 

8.  Resolved,  That  all  papers  and  discussions  of  this  conference 
be  referred  to  the  Committee  on  Publication  with  full  power  to  pub- 
lish the  same  as  they  deem  fit. 

Chairman  Way  moved  the  adoption  of  the  report,  seconded  by 
Dr.  I.  M.  Taylor  of  Morganton,  N.  C,  who  asked  that  it  be  adopted 
unanimously  by  a  rising  vote,  which  was  done. 

A  paper  entitled  "Results  of  Stomach  Analysis  in  Pellagra",  by 
Dr.  W.  O.  Nisbet  of  Charlotte,  N.  C,  was  read  by  title. 

Dr.  J.  H.  Randolph  and  Dr.  R.  N.  Greene,  State  Hospital  for 
Insane,  Chattahoochee,  Fla.,  read  a  joint  paper  entitled  "Further 
Observations  on  Pellagra  with  Points  on  Prognosis." 

Dr.  Rea  Parker,  State  Hospital,  Williamsburg,  Va.,  read  a  paper 
entitled  "Clinical  Observations  of  Four  Cases  of  Pellagra." 

Dr.  J.  M.  Buchanan,  State  Hospital,  Meridian,  Miss.,  read  a  paper 
entitled  "Report  of  Tw^elve  Cases  of  Pellagra." 

Dr.  Sara  A.  Castle  of  Meridian,  Miss.,  followed  with  remarks 
m  which  she  detailed  her  observations  regarding  pellagra  in  Meri- 
dian. 

Dr.  J.  Roddey  Miller  of  Rock  Hill,  S.  C,  read  a  paper  entitled 
"Report  of  a  Case  of  Pellagra  Universalis." 

Dr.  John  Lunney  of  Darlington,  S.  C,  reported  "A  Sporadic  Case 
of  Pellagra." 

Dr.  Theo.  Maddox  of  Union,  S.  C,  read  a  "Report  of  Six  Cases 
of  Pellagra",  after  which  the  conference  adjourned  until  8:30  p.  m. 

Second  Day — Evening  Session. 

The  conference  re-assembled  at  8 :30  p.  m.,  with  Dr.  Wilson  in 
the  chair. 

Dr.  H.  H.  Griffin,  State  Hospital,  Columbia,  S.  C,  read  a  paper 
entitled  "Is  Pellagra  Contagious  or  Hereditary?" 


lO 

This  paper  was  discussed  by  Dr.  John  Forest  of  Charleston,  S.  C. 

A  paper  entitled  "Pellagra  in  Children",  by  Dr.  M.  B.  Young, 
Rock  Hill,  S.  C,  was  read  by  title. 

Dr.  Crown  Torrence  of  Union,  S.  C,  reported  "A  Case  of  Labor 
in  a  Pellagrin  with  Subsequent  History  of  Mother  and  Child." 

A  paper  by  Dr.  D.  S.  Pope,  State  Hospital,  Columbia,  S.  C,  enti; 
tied  "Infants  of  Pellagrous  Parents",  was  read  by  title. 

Dr.  A.  B.  Clarke  of  Plantersville,  S.  C,  read  a  paper  on  "Diseases 
of  the  Eye  in  Pellagra." 

Dr.  Clarke  was  followed  by  Dr.  E.  M.  Whaley  of  Columbia,  S. 
C,  who  read  a  paper  on  "Eye  Symptoms  of  Pellagra." 

Dr.  B.  L.  Eiker  presented  the  Constitution  which  was  prepared 
by  the  Committee  on  Permanent  Organization.  This  Constitution 
in  its  amended  form  is  as  follows : 

Preamble. 

Recognizing  the  necessity  that  has  arisen  demanding  the  further 
study  of  pellagra  in  the  United  States,  and  in  order  to  preserve  and 
protect  the  health  of  our  people  from  a  scourge  that  threatens  to 
become  national,  the  National  Association  of  Pellagra  hereby  adopts 
the  following  Constitution: 

Article  I. 

This  organization  shall  be  known  as  the  National  Association  for 
the  Study  of  Pellagra. 

Article  II. 

The  membership  of  this  association  shall  be  composed  of  medical 
and  scientific  workers,  who  are  interested  in  the  prevention,  study 
and  control  of  pellagra.  The  charter  members  of  this  association 
shall  be  selected  by  the  Board  of  Directors  hereinafter  provided  for, 
from  the  list  of  attending  physicians  registered  at  the  National  Con- 
ference on  Pellagra  held  at  Columbia,  S.  C,  November  3  and  4, 
1909. 

Article  III. 

The  officers  of  this  association  shall  be  a  President,  a  First  Vice- 
President,  a  Secretary,  Treasurer  and  Board  of  Directors. 


II 

Article  IV. 

The  President,  First  Vice  President,  Secretary  and  Treasurer 
shall  be  elected  annually  and  shall  hold  their  offices  for  a  period 
of  one  year,  or  until  their  successors  are  elected.  The  firs 
Vice-President,  Secretary  and  Treasurer,  together  with  four  or 
more  members,  whose  manner  of  selection  shall  be  provided  for  in 
the  By-Laws,  shall  constitute  the  Board  of  Directors. 

Article  V. 

The  meeting  of  this  association  shall  be  held  annually  at  such  time 
and  place  as  may  be  agreed  upon  by  a  majority  of  the  members 
present  at  the  annual  meeting  preceding. 

Article  VI. 

This  association  shall  provide  By-Laws,  Rules  and  Regulations, 
not  otherwise  provided  for,  governing  its  deliberations,  and  the 
President  shall  have  power  to  appoint  committees  to  provide  the 
By-Laws,  Rules  and  Regulations  above  enumerated. 

Article  VII. 

This  Constitution  may  be  amended  at  any  annual  meeting  by  a 
majority  vote  of  all  members  present;  provided  that  notice  of  such 
proposed  amendment  and  vote  thereon  has  first  been  publicly 
announced  at  a  previous  session  of  said  meeting. 

GEO.  A.  ZELLER,  Peoria,  111., 
LOUIS  LEROY,  Memphis,  Tenn., 
E.  M.  MASON,  Montgomery,  Ala., 
E.  L.  EIKER,  Leon,  Iowa, 

Committee. 

Dr.  Kerr,  In  speaking  for  the  Committee  on  Statistics,  said :  I 
have  spoken  to  the  members  of  this  committee  and  the  member- 
ship has  been  made  to  include  members  of  the  State  Boards  of 
Health  and  particulary  in  those  States  where  pellagra  has  attracted 
so  much  attention.  It  is  the  idea  to  continue  and  try  to  make  a 
census  of  the  number  of  cases  of  pellagra  and,  as  was  stated  yester- 
day, this  matter  has  been  taken  up  by  the  Bureau,  but  we  hope  that 
through  this  committee  and  through  the  State  Boards  of  Health  we 
will  be  able  to  make  a  more  complete  report.     As  you  are  aware, 


12 

it  is  practically  impossible  to  make  an  accurate  census  of  cases  of 
pellagra  from  year  to  year  or  to  give  an  accurate  estimate  of  the 
number  of  cases  that  have  prevailed.  It  is  more  important,  however, 
to  secure  enough  statistics  or  as  many  as  we  can  to  determine  the 
geographical  distribution  of  the  disease  and  for  this  purpose  I  see 
great  necessity  in  trying  to  make  a  census  and  of  collecting  all  statis- 
tics possible,  and  since  every  member  and  delegate  of  this  confer- 
ence is  interested  in  this  part  of  the  subject,  I  would  be  very  glad 
to  have  their  co-operation,  and  if  they  have  cases  to  report  to  us, 
we  will  be  glad  to  include  them  in  the  compilation,  but  with  one 
word  of  caution,  namely,  that  we  make  them  a  minimum  rather  than 
a  maximum  number. 

Dr.  C.  F.  Williams  reported,  as  Chairman  of  the  Committee  on 
Publication,  that  in  compliance  with  the  resolution  offered  by  the 
Committee  on  Resolutions,  the  following  committee  had  been 
appointed : 

Dr.  Hyde,  Chicago  111. ;  Dr.  Woodward,  Washington,  D.  C. ;  Dr. 
Byrd,  Jacksonville,  Fla. ;  Dr.  Babcock,  Columbia,  S.  C. 

Our  committee  has  met  and  outlined  a  plan  for  publishing  the 
proceedings  of  the  conference,  and  it  is  our  hope  to  have  the  transac- 
tions ready  for  distribution  by  the  middle  of  January,  but  as  to 
whether  or  not  this  will  be  accomplished  will  depend  largely  upon 
the  time  it  will  take  the  stenographer  to  get  out  his  notes,  and  the 
time  that  will  be  consumed  in  the  revision  of  the  discussions  by  the 
various  participants,  and  the  return  of  the  corrected  copy  to  us. 

Dr.  C.  L.  Minor  called  attention  to  an  oversight  in  the  election 
of  officers,  saying  that  no  provision  had  been  made  for  a  Second 
Vice-President,  and  accordingly  moved  that  Dr.  C.  F.  Williams  be 
elected  as  Second  Vice-President,  which  motion  was  duly  seconded 
and  carried. 

On  motion  the  President  was  requested  to  appoint  a  Board  of 
Directors  to  serve  for  one  year. 

Several  lantern  slides  were  then  shown  by  Drs.  J.  J.  Watson  and 
C.  C.  Bass. 

Doctor  Wilson,  on  behalf  of  the  State  Board  of  Health,  expressed 
thanks  to  the  delegates  for  the  hearty  co-operation  they  had  given, 
and  which  contributed  so  much  in  making  the  conference  a  success. 
He  said  he  was  much  impressed  with  the  earnestness  and  enthusiasm 
shown  in  the  proceedings  of  the  conference  and  he  was  sure  that 
ultimately  we  would  solve  the  mystery  of  pellagra  which  seems  to 
impress  us  all  so  deeply     He  also  wished  to  make  acknowledgment 


13 

in  behalf  of  the  State  Board  of  Health  of  the  work  which  Dr.  Bab- 
cock  has  done  and  is  doing  in  furthering  this  cause.  Dr.  Babcock's 
enthusiasm  had  been  an  inspiration  and  the  conference  was  largely 
due  to  his  activity.     (Applause.) 

There  being  no  further  business,  scientific  or  otherwise,  to  come 
before  the  meeting  the  conference  then  adjourned. 

The  Board  was  then  called  to  order  and  the  following  resolution 
adopted  and  the  Secretary  instructed  to  forward  a  copy  to  Mr.  Rocke- 
feller : 

Resolved,  That  the  Executive  Comniittee  of  the  State  Board  of 
Health  of  South  Carolina  convey  to  Mr.  Rockefeller  their  sincere 
appreciation  of  his  generous  public  spirit  as  expressed  by  his  munifi- 
cent gift  for  the  eradication  of  uncinariasis,  which  has  exerted  such 
a  deleterious  influence  upon  the  physical  and  mental  development  of 
so  large  a  portion  of  the  population  of  the  South. 

There  being  no  further  business  the  Board  adjourned  at  11:30 
p.  m. 

(Signed)     C.  F.  WILLIAMS, 

Secretary. 

Attest : 


14 


INTRODUCTORY  REMARKS 

F.  M.  SANDWITH,  M.  D.^  F,  R.  C.  P. 

Qresham  Professor  of  Physics,  Vice-Presicient  of  the  Society  of  Tropical  Medicine 

and  Hygiene,  Etc. 

LONDON^    BNG. 

Although  my  professional  engag-ements  in  London  prevent  my 
accepting  the  courteous  invitation  of  the  South  Carolina  State  Board 
of  Health  to  attend  the  National  Conference  on  Pellagra,  I  gladly 
avail  myself  of  their  further  request  that  I  should  write  a  short 
paper  on  the  subject. 

I  feel  that  my  first  words  must  be  those  of  congratulation  and 
encouragement  to  the  many  physicians  in  the  Southern  States  who 
are  now  working  at  the  various  problems  connected  with  pellagra. 
Congratulation  in  the  first  place  because  they  have  discovered  the 
existence  of  the  disease,  because  they  have  impressd  this  discovery 
upon  others  so  that  the  presence  of  pellagra  is  now  thoroughly  rec- 
ognized by  competent  observers,  and  because  they  have  provided  us 
with  a  literature  on  the  subject  in  the  English  language.  This  can 
not  but  be  of  interest  to  me,  because,  until  I  began  to  write  on  pel- 
lagra, there  were  apparently  no  literary  contributions  in  our  tongue, 
if  we  except  two  or  three  accounts  written  by  travelers  to  describe 
cases  they  had  seen  in  Italy.  The  English  text  books  were  either 
silent  on  the  subject  or  frankly  ignorant. 

If  I  venture  also  to  encourage  American  co-workers,  it  is  not 
with  any  improper  desire  to  draw  attention  to  my  own  work,  but 
because  I  happen  to  be  in  the  unique  position  (with  regard  to  this 
one  disease)  of  being  able  to  appreciate  their  difficulties. 

So  long  ago  as  1893,  while  preparing  a  paper  on  ankylostomiasis, 
I  became  aware  that  some  of  my  peasant  patients  at  Kasr-el-Ainy 
hospital  in  Egypt  were  suffering  from  dermatitis,  bald  tongue,  diar- 
rhoea, pains  in  the  back,  alteration  of  the  knee  jerk,  insomnia  and 
melancholia,  all  symptoms  which  could  not  legitimately  be  attributed 
to  the  anaemia  caused  by  the  hook  worms.  Quite  ignorant  at  that 
time  of  pellagra,  which  was  not  known  to  exist  outside  Europe  and 
Mexico,  I  determined  to  study  the  disease  in  Italy. 


^5 

Landing  at  Venice,  I  was  disappointed  to  find  that  the  physicians 
of  the  general  hospitals  and  lunatic  asylums  there  were  not  inter- 
ested in  the  disease,  though  at  Milan  and  in  its  neighborhood  I  found 
many  who  were  well  acquainted  with  it,  especially  in  the  lunatic 
asylums  and  at  the  pellagrosarii  or  farm-sanatoria  for  the  care  of 
chronic  patients. 

I  had  no  difficulty  in  identifiying  the  pellagra  of  lower  Egypt 
with  that  of  Italy,  though  the  complications  of  the  disease  are  ob- 
viously different  in  an  Italian  carnivorous  alcoholic,  and  in  an  Egyp- 
tian, who  habitually  takes  little  meat  and  no  alcohol  and  is  likewise 
infested  with  entozoa  {ankylostomum  duodenale  and  Schistosomum 
haematobuim) . 

Upon  my  return  to  Egypt  I  succeeded  in  interesting  a  few  of  my 
English  colleagues  in  pellagra,  but  I  had  to  wait  many  years  to 
induce  the  Egyptian  government  to  make  any  inquiry  into  the  prev- 
alence of  the  disease,  though  my  facts  and  figures  had  never  been 
disputed. 

Maize  (zea  mays)  was  introduced  into  Egypt  as  a  cereal  from 
Syria  about  1840,  yet  pellagra  was  not  discovered  until  1893,  though 
it  had,  perhaps,  been  present  for  years  in  the  country  districts. 

In  spite  of  denial  from  American  authorities  on  medicine,  I  have 
always  suspected  that  pellagra  might  exist,  unrecognized,  in  the 
South,  and  at  one  time  I  requested  my  friends  to  put  me  into  com- 
munication with  the  poorest  folk  of  the  maize-eating  districts.  I 
was  referred  to  a  settlement  in  eastern  Virginia  for  pauper  negroes, 
but,  on  investigation,  I  found  that  the  inmates  lived  in  stone  houses 
on  pork  rations  and  I  came  to  the  conclusion  that  the  word  poverty 
represented  no  condition  in  America  which  could  compare  with  the 
misery  of  the  impoverished  peasants  of  Italy,  Roumania  or  Egypt. 

During  the  South  African  war  I  found  myself  surrounded  by  poor 
colored  folk  living  on  maize,  and  I  naturally  expected  to  meet  with 
some  pellagra  among  them,  but  medical  men  practicing  in  the  coun- 
try assured  me  that  no  such  disease  had  ever  been  seen.  Yet,  in 
the  year  1900,  I  saw  two  cases  of  pellagra  among  the  lunatics  of 
Robben  Island,  Cape  Town,  and  had  previously  recognized  a  third 
case  at  Bethlehem  Hospital  (London),  which  had  been  imported  from 
South  Africa. 

This  reawakened  my  suspicion  with  regard  to  the  United  States, 
and  I  was  not  surprised  in  1902  to  hear  of  the  pellagrous  farmer, 
reported  by  Dr.  H.  F.  Harris  of  Georgia. 

In  April,  1905,  I  had  the  good  fortune  to  be  at  Boston,  Mass., 


i6 

during  an  epidemic  of  cerebro-spinal  meningitis,  and  the  very  first 
patient  whom  I  saw  at  the  City  Hospital,  by  the  courtesy  of  Dr. 
C.  F.  Withington_,  was  an  Italian  immigrant,  who  also  displayed  a 
well  marked  pellagrous  eruption.  This  leads  one  to  wonder  whether 
the  United  States  Public  Health  and  Marine  Hospital  Service 
officers,  who  examine  the  emigrants  at  Naples  and  other  Italian  ports, 
should  not  include  pellagra  among  the  prohibitory  diseases. 

Now  that  the  diagnosis  of  pellagra  has  been  firmly  established  in 
so  many  States,  it  would  be  well  to  find  out  for  certain  how  many 
people  are  attacked  by  the  disease  in  the  South.  In  order  to  arrive 
at  any  correct  figures,  it  might  be  well  to  institute  compulsory  noti- 
fication of  the  disease,  at  least  as  a  temporary  measure.  In  Italy 
there  has  been  a  law  to  that  effect  since  1888.  The  lunatic  asylums 
will  continue  to  yield  a  certain  number  of  advanced  cases,  but  pel- 
lagra should  be  searched  for  among  the  out-patients  of  general  hos- 
pitals, and  in  the  private  practice  of  country  doctors.  I  would  also 
recommend  that  agricultural  laborers  should  be  examined  in  the 
States  where  pellagra  is  known  to  be  prevalent,  such  as  Georgia 
and  North  and  South  Carolina.  This  might  be  done  in  February 
or  March,  when  the  eruption  is  likely  to  be  present. 

In  1 90 1 -'02  I  obtained  permission  to  examine  500  Egyptian  peas- 
ants who  were  actually  at  work  in  the  fields ;  they  all  stoutly  denied 
that  they  were  ill,  and  their  employers,  who  worked  with  them, 
stated  that  they  could  all  do  a  fair  day's  work.  Yet  in  €very  field 
I  found  early  cases  of  pellagra,  varying  from  15  per  cent,  in  well- 
to-do  districts  to  62  per  cent,  in  the  inhabitants  of  the  poorest 
hamlets. 

Though  maize  was  the  last  of  the  great  grain  crops  of  the  world 
to  be  brought  within  the  domain  of  civilized  agriculture,  its  produc- 
tion has  now  attained  such  magnitude  that  in  some  years  it  con- 
stitutes the  greatest  cereal  crop  of  the  world.  As  at  least  three- 
quarters  of  the  world's  maize  crop  is  grown  in  the  United  States,  the 
cultivation  and  curing  of  this  cereal  are  of  supreme  importance  to 
every  American  citizen.  Already  the  question  has  excited  the  inter- 
est of  investigators  like  Dr.  Carl  L.  Alsberg. 

If  a  complete  census  could  be  obtained  of  the  pellagrous  it  might 
be  found  that  the  two  sexes  suffer  equally,  unless  the  women  have  a 
less  varied  diet  than  the  men,  and  I  shall  be  surprised  to  learn  that 
the  children  (after  the  age  of  10)  are  fairly  exempt,  as  more  than 
one  American  writer  has  stated  during  the  last  two  years. 

One  of  the  objections  to  the  diseased  maize  theory  of  causation 


17 

is  that  cases  are  sometimes  reported  of  pellagra  occurring  among 
those  who  have  never  eaten  maize.  In  examining  more  than  i,ooo 
cases  of  pellagra,  I  have  of  course  often  met  with  individuals  who 
stated  that  they  were  not  maize  eaters,  but  on  cross-examination 
every  one  of  them  pleaded  guilty  to  having  occasionally  eaten  bread 
which  was  partly  made  from  maize  flour.  I  therefore  venture  to 
suggest  that  any  undoubted  case  of  pellagra  should  be  thoroughly 
questioned  before  we  inculpate  a  second  cereal  or  attempt  to  over- 
throw the  belief  that  diseased  maize  is  a  potent  factor  in  the  etiology. 

Two  cases  of  pellagra  have  recently  been  recorded  in  patients  who 
had  never  been  out  of  the  British  Isles,  but  the  published  accounts 
do  not  tally  with  the  disease  as  I  know  it,  though  the  symptoms  were 
somewhat  similar  to  pellagra.  One  of  the  patients  had  never  eaten 
maize  but  had  devoured  raw  oatmeal  and  fice. 

A  recent  writer  said  that  he  thought  maize  might  bear  the  same 
relation  to  pellagra  as  the  swamp  does  to  malaria.  I  would  prefer 
to  say  that  maize  may  be  to  pellagra  as  the  mosquito  is  to  malaria, 
remembering  always  that  an  uninfected  Anopheles  is  unable  to  com- 
municate malaria  to  any  human  being. 

The  diagnosis  of  pellagra  is  usually  not  difficult  to  anyone  ac- 
quainted with  the  disease,  but  two  groups  of  patients  have  often 
puzzled  me;  in  the  demented,  unable  to  give  any  account  of  them- 
selves, it  is  sometimes  not  easy  to  determine  whether  pellagra  was 
or  was  not  the  foundation  of  their  mental  failure,  though  sometimes 
the  reappearance  of  a  rash  at  the  advent  of  spring  will  help  to  decide 
the  question.  Another  doubtful  class  of  lunatics  is  affected  with 
real  or  "pseudo-general  paralysis,"  and  in  exceptional  instances 
doubt  may  still  prevail  after  the  autopsy. 

Anyone  hesitating  between  the  diagnosis  of  pellagra  and  leprosy 
must  be  profoundly  ignorant  of  both  diseases. 

I  notice  that  some,  whose  attention  has  lately  been  drawn  to  the 
study  of  pellagra,  are  puzzled  by  the  use  of  the  term  "pseudo-pel- 
lagra," used  by  French  writers.  I  have  never  employed  this  word 
myself;  I  have  never  heard  it  made  use  of,  and  I  know  of  no  cir- 
cumstances under  which  it  need  be  used.  Roussel,  a  French  phy- 
sician, who  wrote  on  pellagra  between  1842  and  1866,  called  certain 
cases  of  "sporadic  pellagra"  in  France,  which  only  faintly  resembled 
the  endemic  disease,  "pseudo-pellagra." 

Most  of  the  cases  of  so-called  "sporadic  pellagra"  clearly  rested 
on  errors  of  diagnosis  during  the  years  which  followed  Roussel's 
discovery  that  pellagra  occurred  in  the  centre  of  France. 

2 — p.  c. 


i8 

Dejeanne,  in  1871,  subjected  these  French  cases  to  a  thorough 
scrutiny  and  wrote  "these  are  maladies  differing  v/idely  among  them- 
selves, and  all  of  them  ver}-  different  from  endemic  pellagra  not  only 
in  the  etiology  but  also  in  the  nature  and  concatenation  of  the  symp- 
toms."   Surely,  it  is  unnecessary'  to  revive  this  antiquated  discussion. 

The  treatment  of  early  cases,  without  mental  symptoms,  can  be 
successfully  accomplished  by  putting  the  patient  on  a  liberal  diet, 
excluding  maize  and  by  ridding  him  of  the  hookworms  which  are 
so  often  co-existent,  but  the  pellagrous  symptoms  return  if  he  is 
allowed  to  resiime  a  diet  of  musty  maize.  Various  preparations  of 
arsenic  are  useful  in  advanced  cases,  but  when  the  brain  is  attacked 
there  is  small  hope  for  the  patient,  unless  by  sero-therapy.  Pellagra 
is  essentially  a  disease  which  cries  for  preventive  measures. 

Italy,  by  preventive  measures,  has,  since  1888,  reduced  the  mor- 
talit}'-  of  pellagra  from  3483  to  1635,  though  during  the  years  1883 
to  1907  the  maize  area  under  cultivation  has  increased  from  5.79 
to  6.33  per  cent,  of  the  whole  country.  This  points  the  moral  that 
it  is  the  quality,  not  the  quantit>',  of  maize  which  is  at  fault.  There 
are  certain  general  axioms  which  prove  true  in  Italy  and  Egypt, 
and  it  will  doubtless  be  foimd  that  they  hold  good  in  the  United 
States  also: 

1.  In  districts  where  no  maize  is  cultivated  or  habitually  eaten,  pel- 
lagra does  not  exist. 

2.  There  are  many  districts  where  maize  has  been  cultivated  for 
many  years  and  yet  pellagra  has  not  appeared. 

3.  Well-to-do  people  in  pellagra  districts,  living  on  varied  diet 
and  consuming  maize  as  an  occasional,  and  not  as  the  staple  cereal, 
usuall}'  escape  pellagra. 

4.  It  is  not  good  maize  or  good  maize  flour  which  produce  pel- 
lagra, the  disease  requires  for  its  production  the  habitual  use  of 
damaged  maize  in  some  form. 

There  is  a  vast  Italian  literature  dealing  with  the  question  of 
what  the  damage  may  be  and  there  is  now  a  ccmsiderable  consensus 
of  opinion  in  favor  of  incriminating  penicillum  glaucum  in  ordinary 
pellagra. 

5.  We  are  constantly  being  reminded  by  sceptics  that  the  maize 
area  of  the  world  is  infinitely  greater  than  the  pellagra  area.  This 
is  not  the  point.  The  question  is,  does  not  pellagra  distribution 
correspond  very  nearly  with  the  areas  upon  which  human  beings 
live  who  eat  damaged  maize  or  products  made  from  damaged  maize  ? 

May  I  be  allowed  to  conclude  these  somewhat  disjointed  remarks 


J 


19 

by  emphasizing  Dr.  James  H.  Randolph's  dictum :  "There  undoubt- 
edly have  been  many  cases  overlooked  in  the  past,  but  the  greatest 
danger  to  be  avoided  in  the  future  is  not  so  much  the  failure  to 
recognize  the  conditions,  but  rather  a  too  great  eagerness  to  diag- 
nose as  pellagra  many  related  disorders. 

We  are  now  waiting,  in  the  confident  hope  that  some  of  the  pel- 
lagra problems,  so  long  unsolved,  may  be  successfully  mastered  in 
the  United  States. 


20 


NOTES  ON  THE  HEMATOLOGY  OF  PELLAGRA 

J.  W.  KERR 
Assistant   Surgeon-General   U.    S.    Public   Health   and   Marine   Hospital    Service. 

When  the  invitation  of  the  State  Board  of  Health  of  South  Caro- 
lina to  attend  this  Conference  was  received  by  the  surgeon  general, 
he  was  obliged  to  forego  the  pleasure  of  acceptance  because  of  pre- 
vious important  engagements.  Nevertheless,  he  is  fully  aware  of 
the  great  importance  of  pellagra  from  the  standpoint  of  the  public 
health,  and  as  he  could  not  be  present  himself,  designated  me  to  rep- 
resent him  in  the  Conference.  On  account  of  the  recent  activities 
of  the  service  in  relation  to  pellagra,  and  because  investigations  of 
the  disease  already  begun  in  the  hygienic  laboratory  are  to  be  greatly 
extended,  it  was  his  determination  that  the  service  should  also  be 
represented  by  a  number  of  other  officers,  among  them  being  Passed 
Assistant  Surgeon  Lavinder,  who,  as  you  are  aware,  has  devoted 
much  time  and  study  to  the  disease — some  of  these  studies  having 
been  made  here  in  Columbia. 

That  pellagra  is  a  serious  disease  there  can  be  no  doubt,  and  it  is 
evident  from  the  studies  already  made  that  its  occurrence  in  the 
United  States  is  a  matter  of  grave  concern.  Even  if  there  were  no 
evidence  that  the  disease  is  on  the  increase,  the  experience  of  coun- 
tries where  it  is  endemic  should  be  sufficient  to  stimulate  active 
interest  and  warn  against  the  dangers  of  its  continued  occurrence. 

In  certain  parts  of  Europe,  where  pellagra  has  long  prevailed,  it 
remains  a  menace  to  the  physical  and  mental  integrity  of  large 
numbers  of  the  population,  and  who  can  estimate  the  economic 
losses  it  has  occasioned  through  sickness  and  death  and  interruption 
to  commercial  activities?  That  they  are  enormous  is  evidenced  by 
the  prolonged  and  careful  attention  given  to  it  by  many  of  the  ablest 
minds  of  those  countries,  and  that  it  is  a  national  problem  of  the 
first  rank  is  shown  by  the  governmental  efforts  in  those  countries 
looking  to  its  control. 

The  problem  of  pellagra  in  Europe  and  the  New  World  is  in  some 
respects  analagous  to  beri  beri  in  the  Orient.  Both  diseases  are 
held  to  be  associated  with  the  consumption  of  important  articles  of 
diet;  both  are  capable  of  becoming  veritable  scourges  among  the 
people  of  the  countries  where  they  become  endemic,  and  in  neither 
disease  has  the  etiology  been  definitely  determined.     This  analogy 


21 

might  be  extended  to  include  communicability,  and  in  some  re- 
spects symptomatology,  and  treatment  of  the  disease.  In  neither 
disease  is  there  evidence  that  communicability  plays  a  part  in  their 
continued  prevalence,  and  in  neither  has  it  been  deemed  advisable 
or  necessary  by  the  National  Government  to  institute  quarantine 
procedures. 

The  Public  Health  Service  in  the  exercise  of  its  quarantine  func- 
tions is  ever  alive  to  the  importance  of  exotic  diseases,  and  has  ac- 
cordingly taken  cognizance  of  reported  cases  in  this  country  and 
abroad.  Through  its  international  quarantine  relations  the  Service 
is  in  a  position  to  have  its  officers  familiarize  themselves  with  the 
public  health  importance  of  such  diseases,  and  make  reports  thereon, 
as  has  been  done  in  the  cases  of  beri  beri  and  pellagra,  reports  to 
the  effect  that  Italian  pellagrins  have  been  and  are  being  rejected 
as  immigrants  by  the  officers  now  on  duty  in  Italy. 

On  account  of  such  reports  and  in  view  of  the  long  experience  of 
Europe  with  pellagra  and  of  the  Orient  with  beri  beri,  it  must  be 
considered  that  those  diseases  are  not  directly  communicable,  and 
that  where  they  prevail  there  also  must  their  causes  be  sought. 
In  other  words,  pellagra  has  been  discovered  in  our  country,  it  has 
in  all  probability  prevailed  for  a  considerable  period,  its  cause  or 
causes  are  to  be  found  among  us,  and  the  occurrence  of  the  disease 
involves  problems  that  will  require  the  most  earnest  investigation 
with  the  view  to  their  solution. 

When  the  first  cases  of  pellagra  were  reported  from  Alabama  in 
1907  an  officer  of  the  Service,  who  had  had  extensive  service  in 
Naples,  Italy — one  of  the  endemic  centres  of  the  disease — invited 
attention  to  the  probable  increasing  importance  of  the  subject  in 
relation  to  the  public  health,  and  recommended  that  investigations 
be  undertaken.  Thereupon,  the  surgeon  general  requested  an 
officer  of  the  Service,  stationed  in  Mobile,  to  report  upon  the  disease 
with  particular  reference  to  its  prevalence  in  Alabama,  which  he  did 
July  20,  1907. 

Subsequently  reports  of  the  occurrence  of  pellagra  in  other  South- 
ern States  began  to  appear,  and  on  April  27,  1908,  Passed  Assistant 
Surgeon  C.  H.  Lavinder,  who  was  then  on  duty  at  the  Marine 
Hospital,  Wilmington,  N.  C,  reported  that  several  cases  of  the  dis- 
ease had  been  observed  in  that  city,  and  that  there  had  been  admitted 
to  the  Marine  Hospital  a  case  which  subsequently  developed  charac- 
teristic symptoms.  In  view  of  this  report,  the  surgeon  general  in- 
vited the  attention  of  Dr.  Lavinder  to  the  increasing  prevalence  of 


22 

the  disease  and  to  the  possibility  that  it  might  soon  assume  im- 
portance both  from  public  health  and  economic  standpoints.  Dr. 
Lavinder  was,  therefore,  instructed  to  prepare  a  precis  on  the  sub- 
ject, and  as  a  result  a  manuscript  was  submitted  July  8,  1908,  which 
was  immediately  published  and  widely  distributed.  It  was  expected 
when  this  article  was  issued  that  it  would  be  the  beginning  of  a 
very  thorough  investigation  of  the  disease,  and  the  progress  of  events 
in  relation  to  pellagra  have  demonstrated  the  wisdom  of  this  deter- 
mination. 

In  his  annual  report  for  1908,  the  surgeon  general  stated  that  pel- 
lagra should  receive  unremitting  study,  and  he  decided  to  detail  an 
officer  of  the  service  who  should  devote  his  entire  time  to  investiga- 
tions of  the  disease.  It  was  with  this  object  in  view  that  Dr.  Lavin- 
der undertook  preliminary  studies  in  the  hygienic  laboratory  and 
later  came  to  this  city  to  avail  himself  of  the  excellent  clinical 
advantages  offered. 

On  March  26,  1909,  an  outline  of  the  proposed  investigations  were 
submitted  to  the  advistory  board  of  the  hygienic  laboratory,  which 
board  is  composed  of  four  officers  of  the  Government  and  five  other 
members  eminent  in  their  respective  scientific  fields  and  connected 
with  corporate  laboratories  of  like  character.  It  was  the  unanimous 
opinion  of  the  board  that  the  primary  investigations  should  be  made 
in  South  Carolina  and  other  places  in  this  country  in  order  that  Dr. 
Lavinder  might  be  better  prepared  to  make  comparable  studies  of 
the  disease  abroad. 

On  account  of  the  clinical  facilities  available  a  working  laboratory 
was  established  at  the  State  Hospital  for  the  Insane  in  Columbia, 
and  the  necessary  material  in  that  institution  was  most  courteously 
placed  at  the  disposal  of  Dr.  Lavinder  by  Dr.  J.  W.  Babcock,  super- 
intendent of  the  asylum,  who  evinced  every  desire  to  lend  aid  during 
the  investigations.  Indeed,  the  State  of  South  Carolina  has  displayed 
great  interest  in  the  pellagra  problem  from  the  beginning,  and 
through  Dr.  C.  F.  Williams,  its  State  health  officer,  has  done  much 
to  stimulate  interest  in  the  grave  situation  which  appears  to  be 
developing  not  only  in  the  South,  but  in  other  sections  of  the  country. 

Early  in  July,  1909,  reports  were  received  from  Nashville,  Tenn., 
and  Chicago,  111.,  stating  that  pellagra  was  thought  to  exist  there, 
and  on  request  Dr.  Lavinder  was  ordered  to  Nashville,  where  he 
found  15  cases  and  to  Dunning,  111.,  where  were  diagnosed  three 
cases.    Up  to  this  time  the  disease  had  been  reported  only  from  the 


23 

Southern  States.     It  was  a  matter  of  much  interest,  therefore,  to 
find  the  disease  existent  also  in  the  North  Central  States. 

In  August,  1909,  the  disease  was  reported  from  the  General  Hos- 
Health  and  Marine  Hospital  Service,  which  was  held  in  Washing- 
ton, June  2,  1909.  Dr.  Williams  of  South  Carolina,  who  was  invited 
to  introduce  the  subject,  presented  a  statistical  paper  by  Lavinder, 
Williams  and  Babcock,  which  was  published  by  the  Bureau  and 
contains  records  of  approximately  1,200  cases  scattered  over  13 
States.  During  the  discussion  Dr.  H.  F.  Harris,  secretary  of  the 
•  State  Board  of  Health  of  Georgia,  referred  to  a  case  of  pellagra 
reported  by  himself  in  1902,  and  stated  that  within  the  past  two  or 
three  years  the  disease  had  increased  in  a  remarkable  manner. 

Since  the  Conference  reports  have  been  received  of  the  occurrence 
of  pellagra  in  a  number  of  other  States,  and  conservative  estimates 
of  the  total  number  of  cases  have  increased  from  1,200  to  over  5,000. 
It  is  not  to  be  inferred  from  this,  however,  that  the  increasing  num- 
ber of  cases  is  due  wholly  to  an  increasing  prevalence  of  the  dis- 
ease. It  is  far  more  likely  that  it  is  largely  a  matter  of  discovering 
existing  cases  as  knowledge  of  the  disease  spreads  and  skill  in  diag- 
nosis develops  among  a  profession  hitherto  largely  unfamiliar  with 
the  subject. 

It  is  of  great  importance  to  determine  the  geographical  distribu- 
tion of  the  disease,  and  above  all,  its  prevalence  in  this  country.  The 
bureau  has  therefore  prepared  and  distributed  blanks  to  health 
officers  throughout  the  country  on  which  to  make  regular  reports  of 
cases  of  pellagra.  Copies  of  these  blanks  are  presented  for  your  infor- 
mation and  it  is  earnestly  requested  that  the  influence  of  this  Con- 
ference be  exerted  to  secure  co-operation  in  the  collection  of  the 
statistical  data  so  much  desired. 

While  the  collection  of  statistics  is  of  primary  importance,  it  is 
only  one  phase  of  the  pellagra  problem.  Arrangements  were 
therefore  made  for  co-operation  on  the  part  of  the  Public 
Health  Service  and  Bureau  of  Plant  Industry  in  the  study  of  the 
topics  in  which  each  was  especially  interested.  In  addition  the 
surgeon  general  determined  to  concentrate  the  energies  of  a  number 
of  scientific  workers  on  certain  phases  of  the  problem  with  the  view  to 
their  elucidation.  He  has  accordingly  appointed  a  pellagra  com- 
mission, whose  membership  consists  of  Passed  Assistant  Surgeon 
John  F.  Anderson,  director  of  the  hygienic  laboratory;  Dr.  Reid 
Hunt,  chief  of  the  division  of  pharmacology  of  the  hygienic  labora- 
tory; Surgeon  M.  J.  Rosenau,  who  is  now  professor  of  preventive 


24 

medicine  and  hygiene  in  Harvard  University ;  Passed  Assistant  Sur- 
geons C.  H.  Lavinder  and  John  D.  Long  of  the  hygienic  laboratory ; 
Dr.  William  A.  White,  superintendent  of  the  Government  Hospital 
for  the  Insane,  Washington,  D.  C,  and  Dr.  Nicolas  Achuccaro  of 
the  Government  Hospital  for  the  Insane,  Washington,  D.  C. 

The  investigations  of  pellagra  already  begun  will  be  greatly  ex- 
tended so  as  to  include  epidemiological,  pathological,  clinical  and 
pharmacological  studies  with  the  hope  of  throwing  additional  light 
on  the  problem  as  presented  in  America  today. 

Pellagra  has  only  recently  been  recognized  in  the  United  States,' 
and  the  medical  profession  as  a  whole  is  not  at  all  familiar  with  its 
manifestations.  In  order  that  the  400  or  more  medical  officers  of 
the  service  might  speedily  become  so,  the  surgeon  general  on  Sep- 
tember 10,  1909,  issued  a  circular  letter  inviting  their  attention  to 
the  subject  and  calling  for  special  reports  from  time  to  time  of  cases 
of  the  disease  coming  under  observation.  In  addition,  23,000  pub- 
lications relating  to  pellagra  have  been  published  for  distribution  by 
the  bureau  as  a  means  of  further  disseminating  information  among 
health  authorities  and  the  medical  profession  generally. 

From  the  foregoing  outline  of  the  steps  already  taken,  it  is  seen 
that  the  surgeon  general  is  deeply  interested  in  pellagra  and  that 
he  regards  it  as  a  public  health  problem  of  national  importance. 
This  does  not  mean  that  there  is  cause  for  panic,  and  he  is  convinced 
that  the  present  popular  interest  in  the  disease  will  resolve  itself  into 
reasonable  prophylaxis  and  improved  sanitation. 

The  belief  that  there  is  some  relation  between  pellagra  and  the 
use  of  corn  as  food  would  seem  too  universal  and  too  profound  to 
permit  of  rejection  except  in  the  case  of  demonstrative  proof  to  the 
contrary.  The  exact  nature  of  this  relation  awaits  final  solution.  In 
the  meantime  it  appears  from  all  evidence  that  sound  com  is  a  highly 
nutritious  and  valuable  food,  and  to  counsel  its  total  rejection 
would  be  inadvisable,  except  for  purposes  of  investigation. 

Finally,  it  must  be  stated  that,  while  the  task  before  this  Confer- 
ence is  one  of  unusual  difficulty,  it  is  worthy  of  the  most  profound 
deliberation,  and  I  am  delegated  by  the  surgeon  general  to  assure 
you  of  his  deep  interest  in  your  work.  He  realizes  that  it  is  through 
G>nferences  such  as  this  that  those  in  attendance  will  receive  in- 
spiration, and  the  people  as  a  whole  be  given  wise  counsel  with  re- 
spect to  prophylaxis  and  improved  habits  of  living. 


25 


ECONOMIC  FACTORS  OF  THE  PELLAGRA  PROBLEM  IN 
SOUTH  CAROLINA 

E.   J.   WATSON 

Commissioner    Department    of    Agriculture,    Commerce    and    Industries 

COLUMBIA,   s.    c. 

Mr.  Chairman  and  Gentlemen  of  the  Conference: 

When  I  stand  here  before  such  a  body  of  distmguished  scientists 
and  professional  men  from  all  parts  of  this  nation  and  from  other 
nations,  I  feel  there  must  be  a  good  reason  why  I  was  asked  to  do 
so.  I  am  one  of  the  official  guardians  of  the  welfare  of  the  people 
and  the  agricultural  and  industrial  future  of  the  Southern  States — 
the  representative  of  the  government  of  this  commonwealth  in  the 
care  of  these  varied  economic  interests.  You  are  here  to  counsel 
as  to  a  grave  danger  that  threatens  not  alone  these  economic  inter- 
ests in  this  State  but  in  the  whole  nation,  and  it  is  timely  that  we 
daily  toilers  for  the  uplift  of  the  people  and  the  fullest  development 
of  natural  resources,  we  practical  protectors  of  sources  of  possible 
disaster,  should  meet  with  you  and  counsel  with  you,  and  then  in 
our  turn  take  the  results  of  your  investigations  and  urge  our  law- 
makers to  place  the  power  of  protection  of  the  unwarned  people  of 
the  commonwealth  in  our  hands.  This  is  the  reason  I  am  before 
you  to  talk  to  you  of  "The  Economic  Factors  of  the  Pellagra  Prob- 
lem." At  least  I  so  take  it.  It  is  a  strong  reason.  "Strong  rea- 
sons make  strong  actions,"  and  I  hope  that  this  conference  will  make 
reasons  so  strong  that  this  State  and  all  the  other  States  shall  not 
delay  in  taking  strong  actions. 

"The  sweat  of  industry  would  dry,  and  die, 
But  for  the  end  it  works  to." 

In  this  problem  of  the  hour  the  end  is  the  same  that  my  official 
oath  binds  me  to  work  to — the  fullest  economic  development  of  my 
State  and  the  ultimate  happiness  and  prosperity  of  her  people. 

"Ignorance  is  the  curse  of  God,"  it  has  been  said,  and  it  is  the 
mission  of  you  distinguished  scientists  to  remove  that  curse.  I  am 
here  to  pledge  you  that  when  you  place  the  instruments  of  removal 
at  our  disposal  and  point  the  way  you  will  not  find  wanting  willing 
workers  in  my  sphere  of  endeavor. 


26 

I  am  not  here  to  attempt  to  discuss  the  etiology  of  pellagra,  to 
attempt  to  say  whether  pellagra  has  its  origin  in  impure  Indian 
corn — the  original  wild  grass  of  the  Mayas  of  Central  America, 
brought  to  us  centuries  after  our  country  was  discovered,  via  Mexico 
by  the  Toltecs  and  the  Aztecs,  given  to  us  by  the  Indians  and  sent 
by  returning  explorers  to  Spain,  Italy  and  other  countries.  I  know 
that  within  the  heart  of  the  corn  kernel,  carefully  encased  in  a 
cylinder  of  oil,  are  life-living  cells.  The  vital  principle  men  of  my 
class  do  not  understand,  but  it  is  there  within  the  womb  of  the 
kernel,  ready  when  healthy  to  burst  forth  into  a  beautiful,  sturdy 
plant  and  bring  forth  an  ear  of  corn  "within  whose  yellow  heart 
there  is  health  and  strength  for  all  the  nations."  We  do  not  know 
that  in  this  kernel  lurks  also  grim  Death.  There  are  reasons  to 
believe  that  this  is  the  case.  We  do  know  that  '"Tis  safer  to  avoid 
what's  grown  than  question  how  it  was  born."  We  know  that  pel- 
lagra exists  in  this  State  and  is  causing  deaths  among  our  people. 

"Judgment  and  reason  have  been  grand  jurymen  since  before 
Noah  was  a  sailor,"  and  this  grand  jury  has  upon  the  testimony  of 
many  scientific  witnesses  rendered  a  true  bill  against  King  Com. 
You  are  here  assembled  today  to  try  the  case  as  petit  jurors  and  to 
render  the  verdict.  If  it  be  "guilty"  then  there  is  all  the  more 
reason  for  me  to  be  here.  When  a  serious  charge — in  this  case 
the  charge  of  murder — is  written  on  the  indictment,  the  subject  of 
the  charge  must  be  held  under  grave  suspicion,  and  such  proper 
precautions  as  are  possible  to  prevent  further  crime  should  be  taken. 
Surely  "'Tis  safer  to  avoid  what's  grown  than  question  how  it  was 
born." 

Our  chief  in  our  sphere  of  endeavor,  that  distinguished  official. 
Secretary  Wilson,  who  has  done  so  much  for  the  people  of  this 
commonwealth,  tells  me.  "I  recognize  fully  the  necessity  of  giving 
every  attention  to  the  pellagra  disease,"  and  "am  naturally  interested 
in  the  question  of  the  relation  of  Indian  corn  to  the  disease." 

Corn  stands  indicted !  When  such  danger  threatens  I  for  one 
believe  in  hoisting  the  red  flag  and  taking  such  precautions  as  our 
limited  knowledge  will  permit.  The  corn  crop  of  this  country  is 
the  principal  crop  of  the  country.  Last  year  it  was  worth  nearly 
as  much  as  the  great  crops  of  cotton,  hay  and  wheat  combined.  It 
amounts  to  over  two  and  a  half  billions  of  bushels,  out  of  the  three 
and  a  quarter  billions  in  the  whole  world,  and  represents  wealth — 
"wealth,"  as  Mr.  Wilson  says,  "taken  out  of  the  soil  in  four  months" 
— of  over  a  billion  and  a  half  dollars,  enough  "to  cancel  the  interest 


27 

bearing  debt  of  the  United  States  and  to  pay  for  the  Panama  Canal 
and  fifty  battleships."  There  has  been  an  increase  in  value  of 
$600,000,000  since  1902,  a  sum  "equal  to  the  gold  in  the  treasury  of 
a  rich  nation."  In  this  little  State  the  corn  crop  last  year  had 
jumped  to  nearly  30,000,000  bushels,  worth  over  26  1-2  millions 
of  dollars,  a  phenomenal  increase  in  two  years  of  practically  ten 
millions  of  dollars.  In  1908  the  nine  cotton-growing  States — the 
Carolinas,  Alabama,  Georgia,  Mississippi,  Louisiana,  Texas,  Okla- 
homa and  Arkansas,  produced  561,103,000  bushels  of  corn — forty 
per  cent,  more  than  Pennsylvania,  Michigan,  Wisconsin,  Minnesota, 
Kansas,  North  Dakota,  South  Dakota,  Colorado  and  New  Mexico, 
which  produced  158,475,000  bushels.  In  the  South  corn-growing 
is  just  beginning  to  reach  for  its  flood  tide,  and  we  are  hourly  bring- 
ing every  influence  possible  to  bear  to  reach  the  goal. 

Corn  is  grown  on  80  per  cent,  of  the  farms  of  the  nation  and  on 
one-eighteenth  of  the  agricultural  acreage,  the  centre  of  production 
being  in  Illinois.  For  the  past  thirty  years  the  North  Central  group 
of  States  has  furnished  about  three-fourths  of  the  total  crop  of  the 
nation.  Some  one  has  figured  it  out  that  if  the  ears  of  the  country's 
corn  crop  were  placed  end  to  end  they  would  encircle  the  earth  at 
the  equator  over  1,100  times;  put  in  cars  of  1,000  bushels  each  the 
crop  would  make  a  train  extending  around  the  world,  and  if  the 
trains  were  composed  of  50  cars  each  it  would  require  50,000  loco- 
motives to  haul  them  to  market. 

No  wonder  we  guardians  of  the  economics  of  the  country  are 
awake  and  up  and  doing,  and  already  hard  at  work  investigating 
sources  of  supply.  No  wonder  we  are  hunting  out  evidence-ex  parte, 
if  you  will,  which  even  gives  a  reasonable  presumption  to  connect 
deaths  of  man  and  beast  with  the  utilization  of  impure  corn  and 
corn  products.  No  wonder,  while  we  regard  Mr.  Rockefeller's 
princely  gift  for  the  eradication  of  the  hookworm  at  its  true  value, 
we  say  one  million  for  the  battle  against  the  disease  of  pellagra 
would  be  far  more  valuable.  In  the  one  case  the  nature  of  the  dis- 
ease and  its  remedy  is  known;  in  the  other  the  remedy  is  unknown. 
No  wonder  we  are  searching  for  evidence  to  show  whether  death- 
dealing  qualities  charged  against  King  Corn  are  developed  in  the 
home-raised  goods  or  in  the  product  brought  in  from  other  States. 

Notwithstanding  this  State  is  now  raising  practically  thirty  mil- 
lion bushels  of  corn  the  people  of  South  Carolina  are  spending  out- 
side of  the  State  for  com  the  sum  of  $6,000,000,  and  this  does  not 
include  the  expenditures — which  are  practically  all  outside  the  State 


28 

— for  grits,  meal,  corn-flakes,  cornstarch,  yeast,  adulteration  in  flour, 
and — well,  I  might  as  well  include  it  too — corn  whiskey!  How 
great  a  sum  these  products  amount  to  I  dare  not  estimate.  And 
South  Carolina  has  no  inspection  law ! 

South  Carolina  buys  these  products  principally  through  the  mar- 
kets at  Nashville,  St.  Louis,  Cincinnati  and  Richmond,  according  to 
the  state  of  the  market,  and  they  are  sold  through  commission  men. 
Practically  no  Texas  corn  reaches  this  State,  and  incidentally  it  may 
be  said,  Texas  corn  seldom  if  ever  spoils  even  on  export,  as  the 
climate  is  such  as  to  thoroughly  cure  it.  This  is  also  largely  true 
of  the  home-raised  product.  Through  the  markets  named  the  corn 
and  corn  products  reaching  the  South  Atlantic  Seaboard  comes 
from  the  corn  belt  States  and  the  States  further  West.  The  prin- 
cipal shipping  States,  the  figures  showing  in  even  numbers  the  por- 
tion of  the  annual  crops  shipped  out  of  the  County  where  grown, 
are  Illinois,  131,363,000  bushels;  Iowa,  77,600,000;  Nebraska,  74,- 
000,000;  Kansas,  34,364,000;  Ohio,  32,802,000;  South  Dakota,  19,- 
000,000;  Indiana,  41,350,000;  Missouri,  20,363,000;  Tennessee,  11,- 
875,000,  and  so  on.  All  know  what  the  weather  conditions  did  to 
the  crop  in  the  third  named  of  these  States  this  summer,  but  I 
am  not  arraigning  any  one  State  or  set  of  States.  I  would  merely 
show  whence  comes  our  supplies  bought  out  of  the  State. 

I  said  we  had  already  begun  to  searchingly  investigate  cases  in 
various  portions  of  the  State  with  a  view  to  tracing,  if  possible,  the 
sources  of  corn  and  com -products  supply  fed  to  man  and  beast,  and 
getting  such  preliminary  data  as  possible,  for  we  have  thousands  of 
our  population  who  never  fail  to  have  their  corn  bread  and  hominy — 
and  this  is  not  confined  alone  to  the  laboring  classes,  to  town  or 
farm,  but  to  all  classes.  We  also  have  thousands  of  head  of  stock 
hourly  endangered  if  the  indictment  against  King  Corn  be  sustained. 
Indeed,  the  entire  "economic  outlook  is  placed  in  jeopardy. 

Let  us  see  what  we  have  found.  A  physician  in  the  Piedmont 
section  tells  me,  "I  have  treated  in  all  ten  cases  of  pellagra.  Six 
of  these  are  dead.  I  have  seen  a  number  of  other  cases  in  consulta- 
tion with  other  physicians.  While  I  believe  most  of  these  cases  were 
caused  by  eating  meal  from  damaged  corn,  still  I  could  not  prove 
that  any  of  them  came  from  any  certain  supply,  for  the  reason  that 
there  is  no  inspection  and  any  and  all  kinds  of  meal  is  sold  without 
restraint.  We  need  a  corn  and  meal  inspection  law  worse  than 
anything  I  know  of." 

Another  physician  in  the  Piedmont,  who  has  observed  75  cases, 


29 

states  that  some  of  them  he  could  not  trace  to  impure  corn  supply. 
He  tells  me  of  a  white  patient  "Traceable  directly  to  spotted  com 
from  a  crop  which  was  grown  on  lowland  and  overflowed  by  a 
swollen  creek  before  harvesting.  One  of  his  patients,  a  white 
woman,  told  him  she  had  eaten  of  com  contrary  to  directions  and 
was  immediately  made  worse." 

Another  close  medical  student  of  the  disease  says :  "Those  cases 
under  my  observation  have  been  consumers  of  grits  and  chiefly 
bread  made  from  corn  meal.  These  corn  products,  as  a  rule,  have 
been  shipped  here  from  the  West.  I  can  not  say  that  my  cases  can 
be  traced  to  the  effects  of  com,  but  can  say  that  the  uses  of  meal 
or  grits  by  those  having  pellagra  produced  an  exacerbation  of  some 
of  the  symptoms.  There  has  been  no  consistent  effort  made  to  prove 
the  meal  or  grits  mouldy  or  spoilt." 

Another  close  student  says:  "I  have  observed  twenty-four  cases 
of  pellagra  in  this  vicinity  since  the  spring  of  1903.  They  have  given 
a  history  of  eating  store-bought  or  Western  meal.  But  I  have  not 
traced  any  of  these  cases  to  any  special  supply.  Twenty  of  these 
cases  were  whites,  some  of  them  in  good  circumstances,  and  four 
were  negroes.  Thirteen  were  white  females,  one  negro  female, 
seven  white  males,  and  three  negro  males.  Of  the  nine  cases  I  have 
observed  in  death,  all  show  mental  derangement  before  death. 
Nearly  all  of  the  meals  used  here  in  town  is  Western  or  shipped 
meal.  On  inquiry  among  the  commission  men  here  I  find  they  buy 
most  of  their  meal  from  Nashville  or  Richmond.  A  lot  of  the 
corn  ground  in  Nashville,  they  say,  comes  from  further  West." 

A  leading  physician  in  upper  Carolina  writes  me  this :  "Our  people 
are  not  yet  restricted  to  any  single  article  of  food.  However,  I  will 
state  that  all  cases  coming  under  my  observation  have  been  eaters  of 
corn  meal  and  grits.  Two  of  them  have  been  great  lovers  of  corn 
bread,  and  practically  the  only  corn  bread  eaters  in  their  families. 
And  the  only  ones  so  far  having  developed  any  symptoms  what- 
ever of  pellagra.  All  of  my  cases  have  occurred  in  separate  fam- 
ilies. I  notice  in  public  print  that  there  are  two  cases  who  never 
ate  corn.  This  in  my  judgment  is  unfortunate,  and  misleading,  since 
it  has  been  only  a  few  years  when  our  wheaten  flour  was  largely 
adulterated  with  heart  corn.  Lombroso  and  a  few  other  scientists 
have  proven  positively  that  the  disease  is  produced  by  the  injection 
of  damaged  corn.  At  present  we  have  no  authentic  information 
that  it  has  been  caused  by  anything  else,  nor  is  it  hereditary.  What 
the  future  will  reveal  I  know  not  but  am  anxiously  waiting." 


30 

Another  physician  presents  another  phase  of  the  inquiry,  when 
he  says :  "I  have  observed  for  years  that  stock  fed  on  corn  over 
which  the  creek  had  run  would  have  'Wind  staggers,'  and  beHeve 
this  is  only  a  symptom  of  pellagra.  I  have  also  noticed  dogs  bury- 
ing bread  in  the  earth,  which  would  soon  mould  and  I  believe  this 
is  a  cause  of  the  so-called  hydrophobia  and  is  nothing  more  than 
pellagra.  From  these  observations  I  am  convinced  that  spoiled 
icorn  plays  a  potent  source  of  this  trouble." 

And  just  here  I  may  say  that  I  have  had  reports  of  the  killing 
of  a^  considerable  number  of  hogs  fed  on  corn  purchased  by  their 
owner,  known  to  be  spoiled.  He  fed  it  against  advice  given  by  his 
neighbors  and  the  death  of  the  animals  ensued.  Another  case  re- 
ported from  the  coast:  The  owner  of  a  number  of  horses  bought 
some  spoiled  Western  corn.  A  ration  was  fed  a  few  and  they  died. 
Orders  were  given  to  feed  it  no  longer.  A  new  stableman  who 
had  not  heard  the  order  came  along  some  weeks  later,  fed  the  corn 
and  $3,600  worth  of  horses  were  sacrificed. 

The  cases  of  the  children  in  a  middle  county  who  ate  warm  meal 
from  their  father's  grist  mill  when  it  was  grinding  bad  "Western 
corn,"  ending  in  their  death  from  pellagra,  while  others  of  the  family 
eating  only  products  of  pure  home-raised  corn  will  be  explained  per- 
haps by  others  at  this  conference.    It  seems  conclusive. 

We  have  found  cases  where  carloads  of  bad  Western  corn  had 
been  placed  on  the  floors  of  warehouses,  leased  for  the  purpose,  by 
commission  men  before  being  offered  to  customers. 

Instances  have  been  reported  of  com  being  ground  into  so-called 
meal  and  shipped  in  after  it  had  been  distilled,  but  specific  cases 
we  have  been  unable  to  find. 

I  am  told  that  much  impure  com  is  distilled  into  corn  whiskey — in 
fact,  that  this  is  a  common  use  for  corn  that  cannot  be  used  other- 
wise. Apropos  of  this,  one  physician  writes  me,  "One  of  my  cases 
(pellagra)  was  a  hard  drinker;  never  ate  corn,  of  course  drank 
corn  whiskey.  Whether  corn  in  this  case  was  the  cause  is  ques- 
tionable." 

But  why  enumerate?  Surely  "unquiet  meals  make  ill  digestion," 
and  ex  parte  statements  implicate  King  Corn  in  the  ruining  of  the 
digestion  of  the  people  of  the  commonwealth  sufficiently  to  make 
us  take  notice. 

What  has  really  awakened  us  to  activity,  however,  is  the  case 
of  a  carload  of  com,  and  we  are  in  possession  of  facts  and  names. 
This  car  of  corn  was  shipped  in  from  the  West  last  June.    A  whole- 


31 

sale  merchant  went  up  to  look  at  it  and  found  it  in  a  damaged 
condition.  He  offered  a  price,  but  the  agent  who  was  trying  to  sell 
it  refused  to  accept  the  price,  stating  "that  he  could  get  a  better 
price  by  selling  it  to  a  mill,  and  it  was  returned  to  Nashville,  Tenn," 
Whether  this  com  came  back  to  this  State  in  the  shape  of  meal,  was 
sent  to  some  other  State,  sold  locally  in  the  form  of  meal,  or  was 
sold  to  distillers,  can  only  be  a  matter  of  conjecture.  It  is  certain, 
however,  that  this  damaged  product  got  into  the  stomachs  of  human 
beings  in  one  form  or  another.  The  same  merchant  says  that  the 
corn  shipped  in  this  year  has  been  in  much  better  condition  than 
heretofore,  and  that  two  years  ago  it  was  exceedingly  bad. 

A  commission  merchant  of  ten  years'  continuous  operation  in  one 
of  the  large  cities,  referring  to  adulterated  food,  impure  grain,  tells 
me :  "I  do  not  believe  there  has  ever  been  a  time  since  I  have  been 
in  the  grain  business  when  so  very  much  swindling  has  been  going 
on  as  at  present,"  and  tells  me  also  of  short  weights  in  meal. 

But,  perhaps,  I  have  bored  you  with  this  hastily  drawn  picture 
of  conditions  leading  us  to  take  cognizance  of  the  indictment  and 
display  vital  interest  in  your  conference.  ^ 

The  Federal  government,  under  the  new  Pure  Food  Law,  doubt- 
less finds  itself  unable  at  this  time  to  afford  adequate  protection.  In 
the  meantime,  if  it  is  true  that  bad  com  and  bad  corn  products 
produce  pellagra — or  even  if  it  isn't  true — and  we  must  go  on  the 
doctrine  of  an  ounce  of  prevention,  then  the  hour  has  arrived  for 
the  States  to  act  speedily  and  decisively  and  at  least  provide  meas- 
ures of  protection  against  the  making  of  such  States  as  South  Car- 
olina the  dumping  ground  for  the  damaged  and  dangerous  products 
of  the  country.  We  have  some  laws  on  our  statute  books,  but  they 
do  not  carry  with  them  means  or  machinery  for  their  rigid  enforce- 
ment. Enough  signs  of  danger — sheet  lightning  they  may  be — 
have  appeared  to  make  decisive  action  imperative  if  the  agricul- 
tural interests  and  even  the  lives  of  the  people  are  to  be  of  any  re- 
gard, and  I  am  no  alarmist. 

There  are  in  this  country  today  only  thirty  States  with  any 
kinds  of  laws  regulating  the  sale  and  inspection  of  concentrated 
feed  stuffs.  Fourteen  of  these  are  Eastern  States,  including  Ohio, 
Indiana,  Illinois,  Wisconsin  and  Michigan.  Ten  are  Southern  States, 
and  only  six  are  Western  States,  even  classing  Oklahoma  in  the 
latter.  The  other  five  are  North  and  South  Dakota,  Washington, 
Iowa  and  Kansas.  Missouri  and  Nebraska  are  among  the  States 
that  have  no  laws  unless  recently  passed.     Meal  is  exempted  from 


32 

the  provisions  of  the  laws  in  nearly  every  State  in  which  we  are 
concerned. 

This  agitation  of  the  whole  question  as  to  whether  or  not  com  is 
the  producing  agency  of  the  disease  of  pellagra — indeed  the  mere 
discovery  of  the  disease — should  admonish  our  people  to  do  what 
we  have  been  pleading  with  them  for  other  economic  reasons  in  sea- 
son and  out  of  season  to  do  for  their  own  protection,  namely,  raise 
their  own  home  supplies.  In  this  climate  corn  matures  and  is  liable 
to  be  pure,  and  our  people  owe  it  to  themselves  and  their  posterity 
to  do  their  part.  Today  there  is  a  mere  handful  of  grist  mills  in 
operation  within  the  State  and  their  business  is  purely  local.  The 
first  step,  then,  from  an  economic .  standpoint,  is  for  the  people  of 
the  ailfected  States  to  raise  and  manufacture,  for  human  food  pur- 
poses, their  own  corn,  and  the  second  is  for  them  to  put  in  full  force 
a  complete  inspection  system,  with  means  and  men  to  execute  the 
laws  when  once  enacted. 

I  fear  I  have  gone  a  little  more  exhaustively  in  this  matter  than 
your  indulgence  would  warrant.  My  only  excuse  is  that  I  realize 
the  vital  importance  of  this  conference,  not  alone  to  the  men,  women 
and  children  of  the  present  generation,  but  to  posterity  in  this 
nation,  in  other  nations,  and  in  this  proud,  prosperous  and  pros- 
pering little  commonwealth.  I  trust  that  your  deliberations  will  lead 
to  results  that  will  themselves,  in  time,  lead  to  the  happiness  of  the 
homes  of  our  common  country,  and  to  the  prosperity  and  above  all 
to  the  preservation  of  the  health  of  the  occupants  of  those  homes. 


33 


NOTES  ON  THE  HEIMATOLOGY  OF  PELLAGRA. 


i 


C.  H.  LAVINDER 

Past  Assistant  Surgeon,  U.  S.   Public  Health  and  Marine  Hospital   Service 

WASHINGTON^    D.    C. 

A  rather  cursory  review  of  the  literature  of  a  subject  so  well 
worked  as  pellagra  impresses  one  with  the  idea  that  the  study  of  the 
blood  in  this  disease  has  been  somewhat  neglected.  Carletti/  in  a 
contribution  on  the  hematology  of  pellagra  in  1903,  said  that  up  to 
that  time  hematological  researches  had  all  been  of  a  partial  nature 
and  devoted  to  some  particular  phases  of  the  question ;  and  that  there 
did  not  exist  in  all  literature  a  complete  study  of  the  subject.  So  far 
as  I  can  learn  from  a  somewhat  hurried  review  of  the  literature 
since  then,  this  statement  is  practically  true  today.  Contributions 
are  constantly  being  made  on  various  points  of  the  subject,  but  com- 
plete studies  appear  to  be  w'anting. 

This  seems  to  me  an  interesting  and  not  unprofitable  field  for 
American  investigators.  Aly  work  on  this  subject  has  been  limited 
and  the  results  as  yet  have  not  been  satisfactorily  collated,  but  a 
brief  review  of  some  points  may  prove  interesting,  if  not  stimulating, 
to  those  interested  in  pellagra. 

Blood  counts,  hernaglohin  estimation  and  differential  leucocyte 
counts. — Carletti,^  summing  up  the  literature  of  cell  counts  and 
hemaglobin  estimation,  reviews  briefly  the  work  of  Lombroso, 
Capezzuoli,  Sepilli,  Agostini  and  D'Ancona  and  Randi,  all  of  whom 
obtained  somewhat  similar  results,  i.  e.,  a  fairly  constant,  though  not 
excessive  reduction  both  in  the  number  of  red  cells  and  in  the  hema- 
globin. Only  one  of  these  workers  reported  on  w^hite  cell  counts 
(Sepilli)  and  he  found  the  number  of  leucocytes  normal. 

With  regard  to  qualitative  changes  in  the  cells  Carletti  states  that 
many  observers  have  made  studies  on  this  point  but  did  not  seem  to 
find  sufficient  changes  to  interest  them.  He  quotes,  however,  Agos- 
tini's  results,  which  were  pallor  of  red  cells,  slight  tendency  to 
rouleaux  formation,  abundant  small  cells  (microcytes?),  poikilo- 
cytosis,  large  leucocytes  with  large  granules  (?),  and  abundant 
pigment  (  ?). 

Carletti,  in  summing  up  his  own  work,  states  that  he  found  a 
constant  mild  reduction  in  the  number  of  red  cells,  much  variability 
in  the  number  of  white  cells,  but  never  a  leucocytosis ;  constant 
3— p.  c. 


34 

reduction  in  hemoglobin  (65  to  75  per  cent.)  with  a  low  color  index 
(0.75  to  0.80).  As  for  qualitative  changes  in  the  cells  he  found 
constant,  but  not  grave,  modifications  with  a  rather  large  number  of 
small  red  cells  (microcytes?)  ;  the  varieties  of  leucocytes  he  found 
retained  their  normal  proportions,  with  a  possible  increase  in  the 
large  mononuclears ;  eosinophiles  he  saw  very  rarely. 

Among  more  recent  workers,  Galesesco  and  Slatineano,^  from  an 
examination  of  31  cases,  report  a  constant  diminution  in  the  number 
of  red  cells  (3  to  4  millions)  without  qualitative  changes;  hema- 
globin  (von  Fleischl)  from  70  to  90  per  cent. ;  slight  increase  in  the 
number  of  leucocytes  (9  to  10  thousand),  differential  counts,  poly- 
nuclears  from  55  to  78  per  cent.,  lymphocytes  17  to  33  per  cent.,  • 
large  mononuclears  10  to  22  per  cent.,  eosinophiles  2  to  4  per  cent. 
They  conclude  that  there  is  a  constant,  large  mononuclear  increase 
from  which  no  deduction  can  be  drawn  as  to  etiology. 

Fratini^  made  a  study  of  34  cases,  both  acute  and  chronic  forms. 
He  used  the  Thoma-Zeiss  counting  apparatus  and  the  von  Fleischl 
hemaglobinometer,  studied  fresh  specimens  and  specimens  stained 
with  Ehrlich's  triacid  stain  after  fixation  in  bichloride  of  mercury; 
and  made  differential  counts.  His  results  were :  A  rather  constant 
reduction  in  the  number  of  red  cells  (3  to  4^^  million)  and  in  the 
hemaglobin  (55  to  92  per  cent.)  ;  white  cell  counts  ranging  from 
7,412  to  11,418;  differential  leucocyte  counts  somewhat  variable, 
but  a  rather  constant  slight  increase  in  eosinophiles  (presumably,  of 
course,  eosinophilic  leucocytes),  which  he  attemps  to  explain  as 
due  to  the  alterations  of  the  intestinal  epithelium  so  common  in 
pellagra.  His  figures  showed  polynuclears,  55  to  76  per  cent. ; 
large  lymphocytes,  2  to  5  per  cent. ;  small  lymphocytes,  18  to  39  per 
cent. ;  eosinophiles,  2  to  9  per  cent.  As  for  qualitative  changes  in 
red  cells  he  reports  rather  constantly  macrocytes,  microcytes,  and 
poikilocytes.  He  also  states  that  he  found  nothing  resembling  a 
protozoal  parasite. 

Manson*  states  that  Sambon  and  Terni,  in  Italy,  and  Grigorescu 
and  Galasescu,  in  Roumania,  have  noticed  a  relative  increase  of  the 
large  mononuclear  leucocytes. 

Fiorini  and  Gavini,^  in  a  study  of  nonalienated  pellagrins,  report 
an  absence  of  leucocytosis,  but  a  typical  mononuclear  increase  and  a 
decided  eosinophilia. 

Masini,**  in  a  study  of  the  eosinophile  cell  in  the  blood  of  pella- 
grins, concludes  that,  contrary  to  what  is  found  in  many  acute 
infectious  diseases,  there  is  produced  in  the  pellagrous  intoxication  a 


35 

conspicuous  and  decided  eosinophilia,  which  occurs  in  cycles  corre- 
sponding with  the  increase  or  diminution  of  the  pellagrogenous  tox- 
ines ;  that  is,  the  more  toxemia  the  greater  the  eosinophilia.  He 
suggests  that  this  constant  eosinophilia  may  prove  at  times  a  valuable 
aid  in  early  or  differential  diagnosis. 

Peserico,"  making  differential  counts  in  several  cases,  obtained 
the  following  results :  Polynuclears,  53.7  to  67.4  per  cent. ;  lym- 
phocytes, 26.1  to  37.4  per  cent,;  large  mononuclears  and  transition- 
als,  1.2  to  "^.J  per  cent.  He  speaks  of  the  nongranular,  large  mono- 
nuclear as  the  hete  noir  of  hematology  and  expresses  much  doubt 
regarding  this  cell. 

These  results  in  many  ways  seem  decidedly  discordant,  but  one 
may  at  least  conclude  that  there  is  a  very  frequent,  usually  mild, 
anemia  of  the  secondary  type,  and  that  if  there  are  qualitative 
changes  in  the  red  cells,  they  are  only  such  as  one  would  expect. 
The  differential  leucocyte  counts  seem  almost  too  discordant  to 
reconcile  in  any  way,  but  there  would  seem  a  majority  opinion  of  a 
definite,  relative,  large  mononuclear  increase. 

While  working  on  pellagra  at  the  State  Hospital  for  the  Insane 
here  in  Columbia,  S.  C,  during  the  past  summer,  I  made  blood 
counts  on  24  cases.    The  results  are  given  in  the  table  below : 


36 


'oraasjY 


■-a 


\   >.<^ 


c3 

a 

a  o 

2  ft' 


(h  a  o 


■^  o  a  .>S 

:  ?;■  o  ■=  5  s 
'  '^  '■^'^  PS 
;     o  r-  o  +^ 


2a 


c:  c  a- 
>-.!>.§  a 


o  o  c  M 
o  o  i:  ^ 


>>-M  i-  "2  Z:  i; 


"    :  >. 


-'C  a  = 


5  a  , 


—  ;-  cj  >5  r 
"■-  o. 


>-5'-.2^-E^.._ 


•2  -d  ■■=  'S  "     .  fcii  ■■;_  vr  r  X  .2  S  r-T  »  ''^  r1  .  . 


o  i;  i.  _-  -  - 


'  ?  ?   -  P  c;  rt  :: 

;££^^aas: 


a  s  j  N  3 
'-  2  iSo 
^  -.s  ?  a 


2  h2 

—        K 


o  c  a  o  c 
■e  -c  "S  E  '3 


^►^Cx?^<C;^J^C,-w^x;=,o 


Ooo^OOOCJl'OOoOoOOOOCOCOOO 

a  (>-,>..  a  >.>..!>..>-,>-,  p^,  n  >-.>-.>.  a  n  a  a  a  a  o  a  a  a 


■jnain 


'GiCOGiOOOOCJOOO' 

.  ^.  a  >s  >-.>-.?>-.  k>  >-.>-.  ;^.  >>  f>j  >i  >s  a 


■SII93 
P3H    Jaqmnx 


^o  ci_x_  X  ft  00  cc  c;  r-_^w  -1"  ir: « :s  o  00 1-  o  cc  •*  c:  tr:  i-c 
cc  Tf  ■rf  Tji  rji  Tj- -^  c<i  c-f -^'ir:  cc  ir:  cc'^'iscc'^'ic  "*'■*■*'  ir:  "* 


■SII9D 


O  C  "I  O  r-  I-  C;  "  rt  C  CO  TT  O  X  O  M-  l-t  r-'  T  K  rf  C  n-  O 

c  :2 ii^L-; r-_i-- x_^ci_o c^oo  ^i  c. c  x  i-  d:  u- oq r:  -s- c  x 
-*  00  CO  -^o  o  ■*  00  ecc  t-^cc"  00  r4cc  c  c;  t-^L3  x't-^t>  ci'o 


-men    -iueD    J9j 


•aSy 


0jg9>J    JO    ajTTIAi. 


*CO 'O 'O 'CO 'O      'O'C      'O      'CO 'O'O fC      'O 

««--.cc_cccoo.'Soo^ci^ooocci^c-'t^ 
>>>o  c  o  c  o'cc'F'c'c'r'o'S'c'o'c'o'c'r'c'5 


aiBraaj  jo  oibk 


•jaqranvj 


OCOCOOO         O  OCOC/CJOOCJOO 

o  0)  o  Kc'sc'c;  el's  cc  o  o'SK'K'S'S'cjItc'eirt 

ecK  2  a  5  a  a  £  BK  EC'S  aassasaasa 


a  ccMtM4H<«-HtMtt-itM  ct«-i  a  a 


37 

The  technique  of  making  these  counts  was  as  follows :  The 
Thoma-Zeiss  counting  chamber,  with  Turck's  ruling,  was  used ;  in 
counting  red  cells  the  four-corner  unit  squares  (25  small  squares 
each)  were  counted  in  two  preparations  and  if  the  results  were  dis- 
cordant, a  third  was  counted;  in  counting  white  cells  the  whole 
ruled  space  was  counted  in  two  preparations,  and  again  if  results 
were  discordant,  a  third  preparation  was  counted.  The  hemaglobin 
estimation  was  made  with  a  new  Dare  instrument,  which  gave  very 
uniform  readings  in  normal  individuals. 

The  cases  were  mostly  of  an  advanced  type  with  many  secondary 
nervous  changes  and  nearly  all  were  alienated.  Most  of  them  were 
negro  women.  The  greatest  number  of  the  counts  were  made  at  the 
same  time  of  day  (morning)  and  under  the  same  circumstances  as 
far  as  possible.  Many  of  the  patients  had  been  taking  arsenic  in  some 
form  with  full  dosage,  either  at  the  time  of  the  examination  or  net 
a  very  long  while  previously. 

A  brief  analysis  of  this  table  shows  a  frequent  reduction  in  red 
cells  and  in  hemaglobin,  and  the  color  loss  would  seem  proportion- 
ately greater  than  the  cell  loss  (chlorotic  type  of  anemia).  There  is 
a  great  variation  in  the  number  of  leucocytes  with  an  occasional 
decided  leucocytosis,  not  clinically  explicable  by  complications  or 
otherwise.  It  is  interesting  to  note  that  numbers  i,  2  and  3  in  the 
table  are  the  same  individual,  before  and  after  arsenical  treatment ; 
and  likewise  4  and  5  are  made  in  the  same  individual;  19,  20  and  21 
are  also  of  interest  as  doubtful  or  cured  cases. 

Differential  leucocyte  counts  were  made  in  several  of  these  cases. 
The  results  generally  showed  a  relative,  large  mononuclear  increase 
with  an  absence  of  eosinophilia,  except  in  cases  with  such  complica- 
tions as  round  worms  or  hookworms.  I  do  not  tabulate  these  counts, 
as  I  do  not  find  the  work  satisfactory  and  distrust  the  results.  As 
will  be  seen  from  the  literature  reviewed  above,  discordant  results 
have  been  obtained  by  other  workers  in  making  differential,  leucocyte 
counts. 

The  technique  adopted  by  me  was  briefly :  Smears  made  on  slides, 
by  using  the  edge  of  another  slide,  stained  by  one  of  the  numerous 
modifications  of  the  Romanowsky  stain,  usually  Wright's ;  and  in 
making  the  counts  the  fringes  of  the  smear  were  avoided  as  far  as 
possible.  The  total  number  of  cells  counted  was  usually  500  or 
more.    A  mechanical  stage  was  used. 

The  classification  was  the  usual  one  of  Ehrlich :  ( i )  Polymor- 
phonuclear neutrophiles,  (2)  small  mononuclears  or  any  nongranu- 


38 

lar  cells  smaller  than  a  polynuclear,  (3)  large  mononuclears  or  any 
nongranular  cell  larger  than  a  polynuclear,  with  a  round  or  oval 
nucleus,  (4)  transitionals,  any  cell  within  the  same  limits  as  a  large 
mononuclear  but  with  an  indented  nucleus,  (5)  eosinophiles,  (6) 
mast  cells  (Emerson).^ 

A  brief  review  of  the  literature  on  this  point  and  my  own  experi- 
ence leads  me  to  question  the  results  achieved  and  I  gravely  doubt 
whether,  from  the  work  done,  we  can  make  any  definite  statements 
as  to  just  what  proportions  the  various  forms  of  leucocytes  in  pella- 
gra may  bear  to  each  other.  The  only  one  general  conclusion  which 
occurs  in  the  work  of  several  is  a  relative,  large  mononuclear 
increase.  This  I  found  with  my  technique  above  described.  It  seems 
to  me  that  unless  each  worker  states  in  full  the  details  of  the  tech- 
nique employed,  the  interpretatiort  and  correlation  of  results  will 
give  rise  to  much  confusion.  The  especial  points  I  would  emphasize 
in  the  technique  are  the  manner  of  making  smears,  the  question  of 
counting  fringes,  and  the  classification  of  the  various  cells.  If  smears 
are  made  on  slides  in  the  manner  done  by  me  and  fringes  are  counted 
the  results  will  be  very  different  from  counts  made  from  the  centers 
of  smears.  Perhaps  cover  glass  smears,  made  in  the  usual  way, 
might  avoid  this  difficulty.  No  matter  what  classification  of  cells  is 
used  the  personal  equation  of  the  counter  must  also  have  its  effect, 
for  there  are  many  doubtful  cells. 

With  regard  to  qualitative  changes  in  the  red  cells  there  are 
undoubtedly,  as  one  would  naturally  expect,  such  changes  as  are 
found  in  any  secondary  anemia,  these  changes  being  in  great 
respect,  of  course,  dependent  upon  the  grade  of  the  anemia.  In  a 
study  of  fresh  smears,  stained  smears  and  smears  made  by  "vital 
staining"  I  found  only  such  changes  as  these  in  my  work. 

I  made  no  accurate  observations  on  coagulation  time,  but  in  draw- 
ing blood  for  various  purposes  from  a  number  of  pellagrins  I  have 
never  observed  any  failure  of  fairly  prompt  and  thorough  clotting. 

Bacteriology  of  the  blood. — The  bacteriology  of  the  blood  in  pella- 
gra forms  a  rather  interesting  chapter  in  the  history  of  this  disease. 
Bacteria,  thought  to  be  specific  in  their  nature,  have  several  times 
been  described  in  the  blood  of  pellagrins.  Majocchi,  Cuboni,  Pal- 
tauf,  Heider^  and  others  did  much  work  on  the  so-called  Bacterium 
maydis;  Carrarioli*  reported  the  Bacillus  pellagrae.  P.  Marie^'' 
states  that  he  observed  in  two  cases  rather  constantly  a  micrococcus, 
which,  however,  he  could  not  grow. 

Quite  recently  Tizzoni^^  has  reported  a  specific  bacterium  which 


39 

he  calls  Streptohacillus  peUagrae  and  which  he  finds  constantly  in 
the  blood  of  pellagrins,  as  well  as  in  the  stools,  the  organs  after 
death,  and  in  spoiled  corn. 

Tizzoni^^  ^  ^-  first  obtained  this  organism  by  simply  incubating  at 
37  degrees  C.  blood  and  spinal  fluid  drawn  from  a  recent  cadaver, 
dead  of  acute  pellagra.  In  his  later  work  on  the  blood  of  chronic 
pellagrins  his  technique,  with  the  blood,  was  to  draw  5  to  10  c.  c, 
allow  serum  to  separate  for  24  hours  at  37  degrees,  and  then  add  this 
serum  to  an  equal  quantity  of  ordinary  bouillon,  incubate  this  mixture 
at  37  degrees  for  3  or  4  days,  and  make  transplants  on  defibrinated, 
rabbit's  blood  agar,  as  well  as  inject  into  guinea  pigs.  He  has  also 
observed  this  micro-organism  in  many  cases  by  making  simply 
stained  smears. 

Wood,  of  Wilmington,  N.  C,  reports  that  he  has  several  times 
isolated  this  micro-organism  from  the  blood  of  pellagrins. 

I  have  been  unable  to  obtain  for  study  a  culture  of  this  organism 
and  in  my  work  I  have  tried  a  number  of  times  to  isolate  it,  but  have 
been  invariably  unsuccessful.  In  fact,  my  experience  in  bacteri- 
ological research  on  the  blood  of  pellagrins  has  been  uniformly 
negative. 

Briefly,  to  sum  up  the  work,  I  have  studied  stained  liver  and 
spleen  smears  made  at  autopsy,  have  made  thick  blood  smears,  laked 
the  hemaglobin  and  stained  the  slide,  have  stained  fresh  and  dried 
smears  in  various  ways,  have  incubated  blood  and  citrated  blood 
(citrate  of  soda,  i  per  cent.)  and  studied  smears  therefrom,  and 
have  put  the  sediment  of  citrated  blood  which  had  stood  for  some 
time,  into  the  peritoneum  of  rats ;  I  have  followed  Tizzoni's  tech- 
nique of  adding  bouillon  to  serum,  planted  blood  and  citrated  blood 
on  various  culture  media;  I  have  injected  blood  into  chickens,  rab- 
bits, guinea  pigs  and  rats — all  with  constantly  negative  results. 

One  fact  I  think  worthy  of  note,  and  that  is  that  one  must  exer- 
cise great  care  in  fresh  smears  of  blood,  or  citrated  blood,  which  has 
stood  for  a  while.  I  have  repeatedly  been  deceived  by  numerous 
small  particules  of  protoplasm,  like  Muller's  blood  dust,  which  have 
a  very  active  Brownian  motion  and  much  resemble  motile  bacteria, 
or  living  parasites. 

In  conclusion  I  would  say: 

(i)  That  there  seems  to  be  present  in  pellagrins  a  fairly  constant 
secondary  anemia,  usually  not  of  a  severe  type,  with  corresponding 
qualitative  changes  in  the  red  blood  cells. 


40 

(2)  That  leucocytosis  is  rarely  seen  in  pellagra  and  that  this  is 
probably  not  a  phenomenon  of  uncomplicated  pellagra. 

(3)  That  the  results  obtained  by  various  workers  on  differential 
leucocyte  counts  are  very  discordant  and  that  conclusions  should  be 
drawn  therefrom  vk^ith  much  hesitation;  though  a  relative,  large 
mononuclear  increase  seems  probable. 

(4)  Th.at  nothing  resembling  a  protozoal  parasite  has  been 
reported  as  observed  in  the  blood  of  pellagrins. 

(5)  That  I  have  found,  in  a  limited  experience,  the  blood  of 
pellagrins  in  South  Carolina  uniformly  sterile  in  cultural  w^ork  and 
not  infective  for  ordinary  laboratory  animals;  and  that  I  have  not 
been  able  to  isolate  Tizzoni's  micro-organism. 

REFERENCES. 

1.  C.irletti.  M.  :     Contribute  all  'ematologia  della  pellagra.     Padova,  1903. 

2.  Galesesco  et   Slatineano :     Examen   du   sang  et   du   liquide   cephalo-racMdien 
dans  la  pellagre.     Compt,  rend.,  soc.  de  biol.,  Paris,  1907,  p.  218. 

3.  Fratinl,   G. :      II   reperto   ematologico   nei   pellagrosi.      Rivista   pella.    Italiana, 
vol.  7,  1907,  p.  167. 

4.  MansoD,   P. :     Tropical  diseases,  4th  ed.,   N.   Y.,   1907. 

5.  Fiorini,   M.,   and    Gavini,   G. :      Contribute   alio    studio   della   formula    emolcu- 
cocltarla  nci  pellagrosi.     Riv.  critica  di  clin.  med.,  190.5,  fasc,  47   (extract.) 

6.  Masinl,  M.  U. :     II  tasso  della  cellule  eoslnophile  nel  sangue  del  pellagrosi. 
Glor.  dl  pslchiat.  clin.  e  tech.  manic,  Ferraria,  1900,  p.  374-381. 

7.  Peserico,  L. :     Sulla  morfologia  del  sangue  nei  pellagrosi.     Morgagni,  Milano, 
1907.   XLIX,   p.   685-695. 

8.  Emerson,  C.  P. :     Clinical  diagnosis.     Phila.,  1908. 

9.  Lombroso,  C. :     Trattato  profilat.  e  clinico  della  pellagra.     Turin,  1892. 

10.  Sclieube,    B.  :      Diseases    of    warm    countries — Article    on    pellagra.      London, 
190.3. 

11.  Tlzzonl,  G.,   and   Fasoli,    G. :      Saggio  di  ricerehe  batteriologiche  sulla  pella- 
gra.— Momorla  dell  'Accademia  dei  Lincei.     Ser.  5,  vol.  6,  Rome,  1906. 

12.  Tizzoni,  G. :     Intorno  alia  patogenesi  ed  etiologia  della  pallagra.     Estratto 
del  Bolletino  del  Minlstero  di  Agricoltura,  Industria  e  Commercio.     Rome,  1909. 


DISCUSSION    ON    THE    PAPERS    OF    DRS.    KERR    AND 

LAVINDER 

Dr.  R.  N.  Greene,  Chattahoochee,  Florida:  I  wish  to  make  a 
few  remarks  on  the  paper  of  Dr.  Lavinder.  Up  to  the  moment  of 
leaving  the  hospital  in  Florida  for  the  purpose  of  attending  this 
conference,  we  had  been  making  differential  blood  counts  in  cases 
of  pellagra,  and  our  findings  have  been  largely  in  conformity  with 
those  reported  by  Dr.  Lavinder.  The  inference  to  be  drawn,  it  seems 
to  me,  is  this :  that  instead  of  making  the  old  stereotype  statement, 
as  we  have  been  making  it,  in  the  absence  of  distinct  signs,  that  in 
measles  or  influenza  large  mononuclear  leucocytes  usually  indicate 
malaria,  it  seems  we  must  add  to  that  list  pellagra.     In  our  investi- 


41 

gations  and  examinations  we  used  the  azure  method  in  combination 
with  eosin,  the  smears  being  taken  by  the  same  men  and  the  counts 
made  by  the  same  men  in  each  case. 

Dr.  C.  C.  Bass,  New  Orleans,  Louisiana :  My  work  in  connection 
with  pellagra  has  been  chiefly  along  the  line  of  hematology,  and 
experimental,  and  I  want  to  emphasize  what  Dr.  Lavinder  said, 
namely,  that  blood  cultures  have  with  me  been  universally  negative, 
and  not  only  have  these  cultures  been  negative,  but  animal  injections 
have  been  likewise  negative  in  results.  In  my  injections  I  have  used 
macerated  cord,  macerated  liver,  macerated  spleen,  and  brain  also, 
but  always  getting  negative  results.  Those  familiar  with  the  path- 
ology of  the  disease  know  that  there  is  usually  a  short  portion  of 
the  cord  very  much  softened.  I  have  taken  that  part  of  the  cord, 
injected  it  into  rabbits,  guinea  pigs  and  chickens,  all  of  which  have 
remained  perfectly  normal.  One  set  ran  as  long  as  three  months. 
Therefore,  it  seems  highly  probable  from  Dr.  Lavinder's  experience, 
and  from  the  work  I  have  been  able  to  do,  we  cannot  inoculate  rab- 
bits, guienea  pigs  and  chickens  with  any  bacterium  that  may  be 
present  in  the  blood  of  patients,  or  in  the  lesion  which  such  patients 
have.  I  want  to  emphasize  the  unreliability  of  differential  blood 
counts,  and  the  absolute  necessity  of  not  drawing  any  conclusions 
whatever  from  differential  blood  counts  made  by  differential  men, 
especially  with  reference  to  the  large  and  small  mononuclear  leuco- 
cytes. Of  all  things  in  the  world,  men  will  disagree  on  in  differ- 
ential blood  counts  it  is  the  proportion  of  large  and  small  mononu- 
clear leucocytes. 

Dr.  Walter  H.  Buhlig,  Chicago,  Illinois :  I  am  very  sorry  to 
say  that  Dr.  James  A.  Egan,  Secretary  of  the  State  Board  of  Health 
of  Illinois,  is  not  here  in  person  to  represent  the  Illinois  delegation. 
The  serious  illness  of  his  wife  has  prevented.  In  his  absence  he  has 
asked  me  to  represent  him. 

Dr.  Egan  began  some  of  this  work  in  Illinois  soon  after  the  dis- 
ease, pellagra,  was  discovered  at  the  Peoria  State  Hospital  for  the 
Insane  by  Dr.  Zellar,  Superintendent  of  the  Hospital,  who  is  on  the 
program  today  to  read  a  paper.  We  have  gone  over  a  number  of 
subjects  there,  but  our  work  is  more  or  less  elementary  as  yet. 
While  we  have  had  a  number  of  striking  results,  they  are  only  sug- 
gestive. I  simply  want  to  say  a  few  words  about  the  hematological 
side  of  the  question.  We  have  made  26  or  t.'j  complete  blood  counts — 


42 

26  red  counts,  I  believe — which  on  an  average  ran  about  4,200,000, 
although  we  found  cases  with  two  million  and  a  half,  and  five  or  six 
cases  of  about  five  million,  and  the  remainder  in  between  these.  As 
a  rule,  we  found  the  color  index  a  little  low,  that  is,  it  was  of  the 
chlorotic  type.  Now  and  then  we  found  it  i  or  .9.  In  one  case  it 
was  1.3.  That  was  a  case  with  a  very  low  red  count,  two  and  a  half 
million. 

With  reference  to  the  variation  of  reds,  we  found  some  striking 
changes  making  a  picture  of  a  severe  anemia.  Megalocytes  were 
usually  present,  but  not  so  often  as  the  microcytes.  In  one  case  I 
found  megaloblasts.  This  was  the  case  of  a  very  sick  pellagrin  in 
which  the  examination  was  made  the  day  before  death.  I  also  found 
in  that  same  patient  one  or  two  red  corpuscles  with  nuclear  particles. 
We  also  looked  for  polychromatophilia,  and  while  we  found  it  now 
and  then,  it  was  not  a  constant  characteristic.  Basophilic  granules 
were  not  found  in  the  red  blood  corpuscles.  We  did  not  learn  any- 
thing from  the  blood  platelets. 

The  white  blood  corpuscle  counts  were  different  from  those 
reported  here.  One  case  only  had  a  leucopenia  of  four  thousand; 
about  half  of  the  cases  were  normal,  estimating  about  10,000  as  the 
upper  limit  of  the  normal.  The  remainder  of  the  counts  were  above 
10,000,  say  from  12,000  to  14,000,  excepting  a  few  high  counts.  In 
one  case  we  found  48,000  whites ;  in  another  case  there  were  36,000. 
In  the  one  with  48,000  I  made  an  autopsy  subsequently,  but  I  did  not 
find  anything  to  account  for  the  increase,  except  a  little  spot  of 
broncho-pneumonia  about  the  size  of  the  end  of  my  thumb,  which 
could  not  have  produced  this  leucocytosis.  Our  experience  has  been 
that  patients  who  have  a  high  count  die.  We  had  eight  high  counts, 
and  of  these  five  patients  died.  Of  these  five,  all  of  them  had  over 
14,000  whites.  Of  the  three  cases  with  high  counts  that  lived,  one 
gave  a  count  of  12,600,  one  14,000,  and  another  19,000,  the  latter  a 
severe  case. 

In  regard  to  the  differential  count,  we  did  not  find  any  increase  in 
the  large  mononuclears  as  reported  here.  The  large  mononuclear  is 
one  of  the  hardest  things  to  tell  from  a  small  mononuclear ;  some- 
times you  can  say  this  is  a  small  mononuclear  and  this  is  a  large  one, 
but  there  are  sizes  between  when  one  is  not  so  sure.  Although  we 
did  not  find  any  increase  in  the  large  mononuclears,  we  did  find  four 
or  five  cases  with  an  increase  in  the  small  mononuclears,  running 
between  45  and  50  per  cent.,  with  a  count  of  over  10,000,  making  a 
true  leucocytosis.     But  when  the  count  was  over  10,000  or  12,000 


43 

we  usually  found  an  increase  in  the  polymorpholnuclears,  but  never 
any  lessening  of  the  eosinophiles  as  one  would  get  in  a  true  leuco- 
cytosis  from  infection.  Once  we  saw  an  eosinophile  percentage  of 
twelve. 

The  anemias  were  secondary  in  type,  sometimes  leaning  toward 
the  chlorotic  side,  and  at  other  times  leaning  toward  the  pernicious 
anemia  picture.  One  has  to  contend  with  this  difficulty  in  interpret- 
ing blood  counts  in  pellagrous  patients,  namely,  that  he  has  not  seen 
the  patient  before,  and,  therefore,  does  not  know  anything  about  the 
blood  of  those  patients  before  they  contracted  pellagra. 

Dr.  Louis  Leroy^  Memphis,  Tennessee:  I  have  but  a  few  cases 
to  report  in  this  line.  My  findings  have  been  largely  in  accord  with 
what  has  been  thus  far  reported.  I  was  surprised  to  hear  the  second 
speaker  say  that  he  had  been  using  the  eosin  and  azure  stain,  for 
this  is  the  one  I  have  used  in  my  work.  I  have  found  in  counting 
all  cells  a  fringe  with  an  average  of  from  lo  to  12  per  cent,  of  large 
mononuclears,  and  about  17  to  18  per  cent,  of  small  mononuclears, 
or  lymphocytes.  I  have  noticed  regular  degeneration  in  a  few  cases, 
that  is,  polychromatic  staining,  and  I  have  noticed  a  little  irregularity 
in  some  of  the  small  cells.  I  have  seen  also  not  infrequently  as  in 
other  secondary  anemias  small  round  cells  which  apparently  were 
thicker  than  usual,  or  spherical  in  appearance,  or  outline,  that  is,  not 
being  provided  with  the  usual  concavity  which  we  find  with  the 
normal  red  cells.  Further  than  that  our  cases  give  an  average  of 
7,000  leucocytes,  with  the  exception  of  one  case  which  I  saw  with 
Dr.  Litterer,  in  which  15,000  leucocytes  were  found,  and  in  which  a 
staphylococcus  infection  was  also  present.  The  nucleated  reds  have 
been  entirely  absent  in  the  few  cases  I  have  had  a  chance  to  observe. 
Altogether  the  picture  has  struck  me  as  being  a  secondary  anemia  of 
the  chlorotic  type.  The  hemoglobin  index  has  averaged  a  little  over 
nine-tenths  per  cent.  only.  In  the  fatal  cases  there  has  been  a  great 
deal  of  inanition.  The  counts  have  been  taken  from  two  days  to  two 
weeks  before  these  patients  have  died.  I  have  not  had  a  chance  to 
make  blood  counts  except  in  those  cases  that  have  died  a  short  time 
afterward. 

Dr.  C.  L.  Minor,  Asheville,  N.  C. :  There  have  been  several  cases 
of  pellagra  in  Asheville  during  the  past  season,  the  first  being  diag- 
nosed by  my  friend  Dr.  Dunn,  who  had  two  or  three  cases  during 
his  term  of  service  at  our  City  Hospital,  and  I  had  three  in  my 


44 

service  following  his.  The  cases  observed  by  us,  with  one  exception, 
left  the  hospital  at  the  end  of  the  season  in  very  good  condition, 
though  they  will  doubtless  relapse  next  spring.  They  were  all  of 
the  ignorant  poor  class  and,  like  all  Southerners,  all  had  eaten  freely 
of  corn  meal,  often  of  the  cheapest  sort.  They  applied  for  admission 
chiefly  on  account  of  the  dermatitis  and  diarrhoea,  the  dermatitis 
having  in  every  case  been  treated  for  various  skin  conditions  by  their 
home  doctors. 

The  mild  cases  all  did  seemingly  well,  and  at  discharge  the  hands 
showed  only  a  little  yellowish  discoloration,  not  enough  to  attract 
attention,  and  in  great  contrast  to  the  angry  red  condition  on  admis- 
sion. 

The  stomatitis  was  present  in  all,  but  was  mild  save  in  the  fatal 
case,  an  acute  one,  w^here  it  was  severe  and  distressing. 

Diarrhoea  was  present  in  all,  but  in  itself  would  not  have  justified 
a  diagnosis,  the  skin  lesions  being  the  chief  diagnostic  feature  in  each 
case.  In  only  one  case  was  there  any  indication  present  or  past  of 
mental  involvement,  this  developing  just  after  discharge  from  my 
service  of  a  case  that  had  been  under  Dr.  Dunn  previously. 

In  one  of  my  cases  the  woman  had  had  the  disease  for  four  years, 
recurring  each  spring,  but  she  paid  very  little  attention  to  the  hands 
or  the  diarrhoea  till  this  year.  In  this  case  there  was  not  merely  a 
pronounced  dermatitis  of  the  backs  of  the  hands  and  lower  forearms 
and  to  a  less  degree  of  the  flexor  surface  of  the  wrists  and  palms, 
but  there  was  an  eruption  on  the  forehead,  chin  and  back  of  the  neck 
which  was  peculiar  in  that  its  surface  was  dark  brown,  dry,  rough 
and  papillary,  looking  somewhat  like  shagreen.  This  cleared  up 
much  more  slowly  than  the  hands. 

With  reference  to  the  treatment,  we,  of  course,  tried  arsenic  and 
many  other  things,  all  with  little  effect.  What  did  do  good,  how- 
ever, was  the  rest,  cleanliness,  care  and  good  food. 

As  to  its  possible  former  existence  in  our  community,  I  am  sure 
that  had  any  of  us  in  the  past  seen  such  a  dermatitis  w^hich  w^e  mis- 
diagnosed we  could  not  have  failed  to  remember  it,  and  none  of  our 
doctors  recall  any  such  skin  lesions  further  than  five  years  back, 
hence  I  believe  the  present  appearance  of  the  disease  is  in  the  nature 
of  a  new  and  more  or  less  epidemic  outbreak. 

As  one  of  the  speakers  has  said,  when  spoiled  corn  meal  as  the 
etiological  factor  is  backed  up  by  such  scientific  workers  as  the 
Italians  we  cannot  possibly  afford  to  entitrely  reject  it  without  care- 
ful study  of  the  whole  question.    Now  that  the  disease  is  attracting 


45 

so  much  attention  from  the  profession,  I  am  sure  that  doctors 
throughout  the  South  will  begin  to  diagnose  the  increasing  number 
of  cases,  and  the  patients,  reading  of  it,  will  with  the  first  appear- 
ance of  symptoms  consult  the  doctor  and  with  early  diagnosis  they 
will  yield  better  results  to  treatment. 

Dr.  Walker  :  If  I  remember  rightly,  the  first  case  of  pellagra  I 
saw  was  about  22  years  ago,  and  since  then  I  have  seen  several  cases 
in  my  practice,  and  I  would  like  to  ask  Dr.  Williams  to  give  the 
record  of  one  case  which  I  think  he  saw  12  or  15  years  ago. 

Dr.  C.  F.  Williams,  Columbia,  South  Carolina:  The  case  Dr. 
Walker  has  asked  me  to  report  was  not  seen  by  me  as  long  ago  as 
he  mentioned.  I  have  been  practicing  medicine  ten  years,  and  this 
case  was  observed  during  the  first  year  of  my  professional  expe- 
rience. I  think  it  was  in  1899  when  I  saw  it.  The  case  was  a 
typical  one  of  pellagra,  but  at  that  time  we  termed  it  exzema.  There 
was  intense  stomatitis,  profuse  diarrhoea,  rapid  emaciation,  and 
finally  delirium  and  death.  We  will  be  able  to  show  you  such  cases 
here  this  evening. 


46 


PELLAGRA— ITS  RECOGNITION  IN  ILLINOIS  AND  THE 
MEASURES  TAKEN  TO  CONTROL  IT 

GEO.  A.  ZELLER  ' 

Superintendent  Peoria  State  Hospital 

PEOEIA,    ILL. 

The  announcement  of  the  recognition  of  pellagra  in  Illinois  dur- 
ing the  past  summer  made  perhaps  as  profound  an  impression  upon 
the  medical  profession  of  the  State  as  any  single  occurrence  within 
its  history. 

Hitherto,  if  in  masked  form,  the  disease  was  present  at  all  in  any  of 
the  deceptive  cutaneous  eruptions,  such  as  eczema,  sunburn,  psoriasis, 
pemphigus,  erysipelas  or  pityriasis,  or  had  manifested  itself  in  the 
form  of  aphthae,  stomatitis,  acute  or  chronic  diarrhoea  and  dysentery, 
it  was  overlooked  and  included  as  one  of  these.  If  a  doubt  arose  in 
the  mind  of  the  practitioner  and  he  consulted  his  textbook  he  was 
told  the  disease  was  limited  to  Italy  and  does  not  occur  in  the  United 
States,  and  if  greater  inquisitiveness  were  to  lead  him  to  consult  the 
latest  and  greatest  work  on  modern  medicine,  he  would  be  rewarded 
with  just  ten  lines  upon  the  subject. 

We  in  Illinois  were  doubly  excused  if  we  excluded  our  State  from 
debatable  territory,  even  if  inquiries  came  from  the  Southern  States 
as  to  the  presence  of  the  disease.  You  of  the  South  have  always  had 
diseases  which  we  had  no  occasion  to  fear,  and  even  in  the  worst 
yellow  fever  epidemics,  when  the  State  was  filled  with  refugees  from 
Memphis,  Vicksburg  and  other  points,  we  looked  upon  their  presence 
with  impunity,  conscious  that  the  disease  could  not  find  an  abiding 
place  in  our  latitude. 

If  we  ever  quarantined  against  the  South  it  was  only  in  the  ex- 
treme southern  part  of  the  State  along  the  Ohio  River.  Almost  as 
unconcernedly  do  we  even  now  view  the  agitation  caused  by  the  dis- 
covery of  the  hookworm,  for  we  are  told  that  only  a  sporadic  case 
can  occur  in  our  latitude,  and  under  no  circumstances  would  the 
larvffi  mature  to  spread  further  infection. 

Why,  then,  be  agitated  when  an  inquiry  came  from  South  Carolina 
last  winter  as  to  whether  we  had  pellagra? 

Of  course  not,  for  we  were  immune  on  climatic  grounds  and  upon 
the  adidtional  assurance  that  it  does  not  occur  in  the  United  States. 

Even  its  recognition  by  Dr.  Willhite  in  the  Dunning  Institute  at 
Chicago  in  June  of  this  year,  and  its  verification  by  Dr.  Lavinder, 


47 

occasioned  no  particular  comment,  neither  did  the  presence  of  the 

disease  in  the  Elgin,  Illinois,  State  Hospital,  as  reported  by  Superin- 
tendent Podstata,  attract  special  attention.  In  the  former  institution 
there  have  been  to  date  twenty-six  cases,  with  fifteen  deaths,  and  in 
the  latter  a  lesser  number  of  cases,  also  several  deaths. 

I  must  confess  that  I  was  floating  along  in  fancied  security,  ascrib- 
ing to  trophic  changes,  sunburns  and  even  worse  misfortunes,  the 
many  cutaneous  lesions  that  developed  from  time  to  time  among 
those  who  died  of  my  twenty-one  hundred  and  fifty  patients. 

Intestinal  symptoms  were  accounted  for  with  equal  plausibility  in- 
asmuch as  asylum  diarrhoea  has  reached  the  dignity  of  being  included 
in  some  textbooks  on  intestinal  diseases. 

r  never  accepted  it  as  a  permissible  or  excusable  condition,  and 
fought  its  return  each  summer  with  a  vigorous  sanitary  campaign, 
an  anti-fly  crusade  and  finally  by  the  addition  of  seven  lesser  kitchens 
for  the  preparation  of  special  diet. 

Ours  was  the  asylum  for  the  incurable  insane,  and  was  made  up  of 
the  residual  population  of  the  other  asylums  and  the  insane  inmates 
of  the  almshouses.  Many  were  decrepit,  with  terminal  dementia 
quite  common,  and  an  annual  death  rate  of  fourteen  per  cent,  was 
not  apparently  out  of  proportion,  but  whenever  a  death  from  pre- 
ventable disease  occurred  I  went  carefully  into  the  causes  that  led 
up  to  it,  and  every  such  case  was  thoroughly  discussed  at  the  staff 
meeting,  where  nine  active  members  gather  daily  for  that  purpose. 

One  day  Dr.  F.  J.  Griffin,  one  of  my  assistant  physicians,  an- 
nounced to  me  that  he  thought  he  had  a  case  of  pellagra,  and  I  went 
with  him  to  the  cottage  at  once  and  saw  a  most  typical  manifesta- 
tion, and  in  the  case  presented  I  immediately  recognized  a  condition 
that  had  long  been  with  us.  It  was  not  the  individual  case  or  the 
dozen  more  that  I  found  sitting  about  the  porches  with  more  or  less 
pronounced  symptoms  of  the  disease,  but  the  memories  which  they 
evoked  gave  them  a  significance  far  out  of  proportion  to  the  actual 
number  of  patients  at  hand.  They  brought  up  the  existence  of  simi- 
lar lesions  of  varying  degree  where  explanations  to  the  friends  of  the 
patients  had  become  necessary. 

Instantly  my  mind  went  back  to  the  constantly  increasing  number 
of  sunburns  of  the  previous  years,  and  I  realized  that  we  were  dealing 
with  a  condition  that  was  not  new.  I  went  to  the  correspondence 
files  and  quoted  the  following  words  in  the  case  of  the  death  of  a 
very  excellent  lady  whose  body  was  shipped  to  Canada : 


48 

"One  afternoon  she  sunburned  her  hands  slightly  while  out  in  the 
woods,  where  she  was  taken  with  a  number  of  other  patients  for 
amusement  and  pleasure." 

In  another  instance  in  1908,  where  the  friends  became  suspicious 
of  excoriated  hands  and  accused  us  of  burning  the  patient,  the  fol- 
lowing language  was  used : 

"Being  an  invalid  he  was  allowed  to  remain  in  the  open  air  as 
much  as  possible,  and  during  this  time  his  hands  became  sunburned, 
as  is  not  infrequently  the  case  with  these  patients.  The  sunburns 
were  kept  in  proper  dressing  and  were  practically  healed  at  the  time 
of  his  death,  and  were  in  no  way  a  factor  causing  it." 

In  March  of  the  present  year,  immediately  upon  my  return  from 
a  hurried  tour  of  Europe,  I  called  the  thirty-head  attendants  into  my 
office  and  lectured  to  them  at  length  upon  the  necessity  of  observing 
greater  care  in  exposing  patients  to  the  sunlight,  citing  the  numerous 
instances  where  the  lesions  had  become  sufficiently  pronounced  to 
cause  distress  if  not  to  contribute  in  a  measure  to  a  fatal  termina- 
tion. 

The  Peoria  State  Hospital  is  a  cottage-plan  institution  of  thirty 
buildings  and  twenty-one  hundred  and  fifty  patients.  Each  cottage 
has  a  front  and  rear  ground  floor  porch  co-equal  with  the  dimensions 
of  the  building,  and  capable  of  accommodating  the  entire  ward.  The 
open  door  prevails  throughout,  and  upon  these  porches  the  patients 
spend  almost  the  whole  of  each  pleasant  day,  and  for  this  reason, 
unless  carefully  shifted  from  the  sunny  to  the  shady  side,  are  ex- 
posed to  an  unusual  degree  of  sunlight.  Since  no  less  authority 
than  Lombroso  himself  says  that  no  diagnostic  eye  can  differentiate 
between  pellagra  and  sunburn,  we  thought  that  we  had  a  logical  ex- 
planation of  these  lesions,  and  sought  to  prevent  them  upon  this 
hypothesis. 

Our  biennial  report  for  1906  and  1908  each  makes  mention  of  a 
fatality  due  to  scalds  incurred  while  bathing  patients.  In  each 
instance  the  scald  extended  to  a  line  about  four  inches  above  the 
ankles,  bullae  formed  and  desquamation  followed.  The  treatment 
applied  was  that  usual  in  a  burn  of  the  second  degree.  The  greatest 
concern  was  felt  in  these  cases,  and  no  effort  was  spared  to  prolong 
their  lives.  They  were  certain  to  become  the  subject  of  the  most 
rigid  investigation  and  severe  criticism  of  institutional  methods  was 
sure  to  ensue.  The  one  patient  survived  one  day,  the  other  eleven 
days,  and  in  both  instances  the  coroner  was  called.  The  nurses  in 
charge  stoutly  denied  having  scalded  the  patients,  but  appearances 


49 

were  so  overwhelmingly  against  them  that  their  summary  dismissal 
was  considered  a  minimum  penalty,  and  was  promptly  ordered. 

I  will  exhibit  photographs  today  that  would  exculpate  those  gurses 
and  strike  a  blow  at  circumstantial  evidence  that  no  criminologist 
would  deem  possible.  In  fact,  I  have  already  written  to  them  and 
tendered  them  their  former  positions,  and  assured  them  that  if  the 
feeling  that  they  were  instrumental  in  the  loss  of  a  human  life  was 
weighing  upon  them,  they  could  dismiss  the  thought  in  the  newer 
light  that  has  come  to  us  by  reason  of  the  recognition  of  this  new-old 
disease.  I  am  aware  that  I  invite  ridicule  when  I  go  back  to  the  dead 
and  attempt  to  ascribe  a  condition  to  causes  other  than  those  accepted 
at  the  time,  but  my  own  testimony  before  the  coroner's  jury  was  that 
in  neither  case  were  the  scalds  sufficient  to  produce  death  in  a  normal 
individual ;  but  I  had  no  other  explanation  to  offer  at  the  time,  nor 
would  one  of  you  have  advanced  a  different  theory,  although  in  the 
future  such  occurrences  will  at  least  cause  us  to  exclude  pellagra 
before  we  condemn  a  possibly  innocent  person. 

These  circumstances  are  related  not  to  substantiate  the  fact  that  we 
have  pellagra  with  us  at  present,  for  that  is  undisputed,  but  they  are 
resurrected  for  the  purpose  of  demonstrating  that  the  disease  in  one 
form  or  another  has  been  with  us  unrecognized  for  a  number  of 
years.  To  establish  or  disprove  this  theory  is  an  all-important  point 
in  the  study  of  the  history  of  the  disease. 

If  there  is  such  a  thing  as  jumping  at  a  conclusion  I  did  so  on 
August  7,  1909,  but  I  did  so  with  a  clear  knowledge  of  seven  years' 
occurrences  to  guide  me,  and  a  hurried  inspection  of  the  hands  and 
features  of  my  patients  that  revealed  twenty  cases  and  opened  the 
possibility  of  many  more.  That  day  I  sent  the  Secretary  of  the  State 
Board  of  Charities  a  telegram  announcing  twenty  cases  of  pellagra 
in  the  institution,  and  forwarded  letters  of  the  same  purport  to  the 
Governor  and  to  the  Secretary  of  the  State  Board  of  Health.  Recog- 
nizing the  fact  that  a  positive  diagnosis  could  only  come  from  those 
familiar  with  the  disease,  I  wrote  to  the  Surgeon-Generals  of  the 
Army  and  of  the  Marine  Hospital  Service  also,  inviting  their  co-oper- 
ation in  the  study  of  the  disease. 

The  response  was  prompt  from  every  source.  The  Governor 
called  me  up  within  an  hour  and  next  day  sent  a  representative  from 
the  State  Board  of  Health,  and  Dr.  Lavinder  came  out  from  South 
Carolina  by  order  of  the  Surgeon-General  of  his  department,  saw 
thirty  or  forty  cases,  diagnosed  the  disease  and  returned  to  his  post. 
Captain  Siler,  of  the  Army  Medical  Corps,  came  soon  after  and  was 

4— p.  c. 


50 

joined  later  by  Captain  Nichols,  and  the  two  officers  spent  a  month 
in  a  careful  and  systematic  study  of  every  phase  of  the  disease,  and 
the  result  of  their  labors  is  in  print  and  will  constitute  a  valuable 
addition  to  the  literature  of  pellagra. 

Simultaneous  with  their  arrival  came  Dr.  Buhlig,  of  the  North- 
western Medical  School  of  Chicago,  at  the  request  of  the  Illinois 
State  Board  of  Health.  We  added  such  equipment  to  our  laboratory 
as  was  indicated,  and  he  had  an  assistant  on  the  grounds  for  one 
month,  during  which  time  he  himself  made  many  visits.  Distin- 
guished men  from  all  parts  of  the  State  came  to  study  the  disease,  and 
a  visit  from  the  State  Board  of  Charities,  headed  by  Dr.  Frank  Bill- 
ings, resulted  in  a  recommendation  to  "the  Governor  that  a  comrnis- 
sion  be  appointed  to  investigate  the  disease  and  incidentally  the  food 
supply  of  all  the  State  institutions  of  Illinois. 

Upon  this  recommendation  the  Governor  named  a  commission 
which,  in  point  of  intellectual  ability  and  professional  attainments, 
would  be  hard  to  duplicate  in  any  State  of  the  Union.  The  commis- 
sion is  just  organizing,  and  it  would  be  premature  to  speak  of  its 
work,  but  that  new  light  will  be  shed  upon  the  subject  of  pellagra  no 
one  conversant  with  the  high  character  of  the  Board  will  for  one 
moment  doubt. 

I  aimed  only  to  deal  with  the  recognition  of  pellagra  in  Illinors,  and 
in  a  conference  of  this  magnitude,  where  the  subject  will  be  treated 
from  every  possible  viewpoint,  I  have  no  right  to  digress.  I  will  add, 
however,  that  I  regard  the  spread  of  pellagra  in  the  United  States 
as  a  very  grave  matter.  Seeing  it  develop  in  every  ward  of  my  insti- 
tution and  to  the  larger  extent  in  the  tent  colonies  for  consumptives 
where  the  most  nutritious  diet  of  milk  and  eggs  is  given,  seeing  it 
develop  in  men  and  women  of  splendid  physique  as  well  as  among 
those  showing  more  marked  mental  and  physical  decline,  I  can  only 
await  with  dread  its  appearance  in  the  citizenship  outside  the  institu- 
tions. Rumors  of  such  cases  have  reached  me,  but  not  until  Sunday, 
October  24th,  was  a  clearly  defined  case  brought  to  my  attention. 
The  victim  is  a  well  to  do  man  of  seventy,  living  the  life  of  a  retired 
farmer  in  a  city  of  ten  thousand  population. 

He  was  brought  to  the  asylum  by  his  family  physician  for  diag- 
nosis, and  it  was  clearly  and  easily  made.  He  has  the  typical  marks 
of  the  disease,  although  at  present  experiencing  but  little  distress. 
His  case  is  most  significant  if  it  is  the  precursor  of  an  invasion  that 
seems  to  have  found  in  the  skin  and  alimentary  canal  of  the  Ameri- 
can a  fertile  field  for  extension.    Ileave  for  others  the  presentation 


51 

of  the  various  theories  of  its  etiology,  but  desire  to  say  that  an 
amount  of  work  along  every  line  has  been  done  in  our  institution 
since  August  7th  that  would  hardly  seem  possible,  all  of  which  will 
eventually  reach  the  interested  world. 

This  is  the  situation  as  it  stands  in  Illinois  today,  and  it  requires 
no  gift  of  prophecy  to  foresee  that  when  solar  influences  become 
active  next  year,  and  with  the  interest  of  the  profession  thoroughly 
aroused  in  an  endeavor  to  detect  the  disease,  the  center  of  interest 
will  be  in  the  Mississippi  Valley,  and  very  likely  in  the  Peoria  State 
Hospital.  For  that  reason  I  propose  that  the  next  National  Confer- 
ence on  pellagra  be  held  in  Peoria,  111.,  about  the  middle  of  June, 
and  that  an  association  be  formed  here  today  for  the  further  prose- 
cution of  the  study  of  the  disease.  Illinois,  as  the  greatest  of  the 
corn-producing  States,  cannot  but  feel  an  absorbing  interest  in  a 
condition  ascribed  to  its  principal  product,  and  I  am  here  to  assure 
every  active  worker  every  possible  aid  in  his  researches.  By  that 
time  the  knowledge  of  the  disease  will  have  spread  to  every  State, 
and  an  assemblage  of  this  character  will  bring  information  from  the 
remotest  section  in  the  country. 

To  sum  up  the  situation  in  the  Peoria  State  Hospital,  on  November 
1st  I  will  say  that  since  August  loth  there  have  been  officially  recog- 
nized 130  well  defined  and  diagnosed  cases  of  pellagra,  with  one  hun- 
dred additional  cases  on  the  wards  with  symptoms  sufficiently  pro- 
nounced to  warrant  their  inclusion,  but  who  for  the  present  are  suf- 
fering no  inconvenience.  They  are  being  carefully  charted  and  will 
form  the  basis  of  observation  for  next  year. 

Of  the  130  cases,  75  were  women  and  55  men. 

Of  these,  30  women  and  15  men,  a  total  of  45,  died  since  August 
loth. 

Post-morten  examinations  were  held  in  36  of  these  cases. 

Of  the  living,  the  average  age  is  51  years. 

Average  number  of  years  insane,  16. 

Average  period  resident  in  this  institution,  31-2  years. 

Of  the  dead,  the  average  age  at  death  was  54  years. 

Average  length  of  time  insane  of  those  who  died,  17  years. 

Average  period  of  residence  in  this  institution  of  those  who  died 
was  4  years. 

Of  the  living  and  dead,  the  average  age  was  51  years. 

Average  period  insane  of  the  living  and  dead,  15  years. 

Average  period  of  residence  of  the  living  and  dead  in  this  institu- 
tion, 4  years. 


52 

Of  the  total  cases,  12  were  received  from  other  asylums  within  the 
current  year. 

The  death  rate  of  cases  actually  transferred  to  the  hospital  for 
treatment  has  been  34  per  cent. 

The  youngest  pellagrin  was  22  years  old. 

The  oldest  was  85  years  old. 

Of  the  total,  12  were  epileptics  and  seven  were  in  an  advanced 
stage  of  tuberculosis. 

The  list  contains  but  one  colored  person,  a  man,  who  survives  with 
marked  dry  and  thickened  palmar  tissue. 

If  to  these  are  added  the  100  living  cases  still  on  the  wards,  the 
mortality  stands  20  per  cent. 

In  conclusion,  I  trust  that  the  conference  will  not  take  my  confes- 
sion too  seriously.  The  early  California  pioneers  looked  for  a  long 
time  with  unconcern  at  the  black  sand  in  the  creek  bottom  before  they 
found  that  it  contained  gold,  and  many  apples  fell  from  the  trees 
before  Sir  Isaac  Newton  discovered  the  law  of  gravitation. 

Wherever  the  disease  has  been  newly  recognized  there  invariably 
came  an  admission  that  conditions  somewhat  similar  had  existed  for 
years  and  had  been  overlooked,  and  in  some  instances  institutional 
authorities  recalled  cases  as  far  as  thirty  years  back,  therefore  I  feel 
that  I  owe  no  particular  apology  for  the  oversight ;  but  do  feel,  now 
that  we  are  face  to  face  with  the  condition,  that  we  should  meet  it 
energetically,  intelligently,  and  always,  so  far  as  I  am  concerned  at 
least,  with  the  feeling  that  we  are  menaced  with  a  national  scourge. 


53 


ASPECTS  OF  THE  PELLAGRA  PROBLEM  IN  ILLINOIS 

J.   F.   SILER 
Captain  Medical  Corps,  U.  S.  Army 

Part  I. — A  Statistical  Study  of  100  Cases  at  the  Peoria  State  Hospital. 

HENRY  J.  NICHOLS 
Captain  Medical  Corps,  U.   S.   Army. 

Part  II. — Notes   on  the   Epidemiology   of  Pellagra. 

PART  I. 

A  study  of  the  literature  on  pellagra  reveals  the  fact  that  not  only 
is  the  etiology  an  unknown  quantity,  but  the  clinical  picture  of  the 
disease  is  a  most  variable  and  changeable  one.  From  personal 
observation  and  a  study  of  summarized  cases  histories  of  the 
patients  at  Peoria,  we  have  attempted  to  determine  as  to  whether 
or  not  any  constant  symptoms  and  pathalogical  findings  may  be 
noted.  For  statistical  purposes  we  selected  lOO  cases  for  study,  and 
the  figures  presented,  with  few  exceptions,  are  based  on  this  number 
of  cases.  As  pellagra  was  officially  recognized  at  Peoria  about 
August  loth,  in  the  midst  of  the  period  of  acute  exacerbation  (May 
to  November),  it  is  entirely  a  matter  of  conjecture  as  to  the  extent  of 
its  prevalence  in  the  Peoria  State  Hospital.  About  August  22d 
the  entire  institution,  consisting  of  2,140  inmates,  was  examined 
for  pellagra,  with  the  result  that  about  70  patients  presented  typical 
symptoms,  and  150  additional  patients  were  classified  as  typical  or 
suspicious  cases.  Patients  presenting  the  typical  symptoms  of  an 
acute  attack  rapidly  increased,  and  on  the  date  of  our  departure, 
September  24th,  it  could  conservatively  be  stated  that  at  least  125 
patients  showed  acute  pellagrous  symptoms. 

Age  of  Pellagrous  Patients — The  average  age  of  patients  in  the 
Peoria  State  Hospital  was  47 ;  the  average  age  of  pellagrous  patients 
was  50 ;  the  average  age  of  those  who  died  in  the  institution  was  57, 
while  the  average  age  of  pellagrous  patients  who  died  was  55,  only 
two  years  below  the  general  average  age.     As  to  age  decades : 

From  20  to  29  years,  4  cases. 
From  30  to  39  years,  18  cases. 
From  40  to  49  years,  28  cases. 
From  50  to  59  years,  29  cases. 


54 

From  60  to  69  years,  16  cases. 

From  70  to  79  years,     3  cases. 

From  80  to  89  years,    2  cases. 

In  75  per  cent,  of  the  cases  the  patients  were  between  40  and  59, 
the  youngest  being  22,  the  oldest  85. 

Previous  Attacks  of  Pellagra — An  effort  was  made  to  trace  the 
disease  through  previous  years.  The  members  of  the  medical  staff 
and  selected  nurses  and  attendants  who  had  been  connected  with  the 
institution  for  several  years  were  closely  questioned  concerning  the 
previous  appearance  of  pellagra  among  these  patients.  The  fact 
was  easily  established,  in  each  case,  on  the  testimony  of  2,  3,  4  and 
occasionally  5  and  6  different  medical  officers  and  nurses,  that  pel- 
lagra had  been  prevalent  in  this  institution  for  at  least  three  years 
prior  to  the  summer  of  1909.  Seventy-two  per  cent,  of  the  cases 
under  discussion  had  suffered  from  previous  attacks  during  the 
summer  months,  the  average  number  of  attacks  being  two.  Of 
those  who  had  suffered  from  previous  attacks,  25  per  cent,  gave  a 
history  of  three  previous  attacks,  52  gave  a  history  of  two  previous 
attacks,  and  23  per  cent,  gave  a  history  of  one  previous  attack.  Dur- 
ing previous  years  these  cases  were  thought  to  be  cases  of  severe 
sunburn. 

Duration  of  Insanity — The  average  duration  of  insanity  in  this 
series  of  cases  is  13  years.  Thirteen  years'  institutional  life  may 
have  some  bearing  on  the  development  of  the  disease.  Pellagrous 
cases  making  up  this  series  have  averaged  four  years  at  the  Peoria 
State  Hospital.  These  two  facts,  average  duration  insanity  and 
average  stay  at  Peoria,  would  seem  to  indicate  that  the  exciting 
cause  of  the  disease  is  present  within  the  institution.  At  the  same 
time  no  nurses,  attendants  or  employees  have  shown  the  disease. 

Distribution  as  to  Sex — Fifty-six  of  the  cases  were  females ;  44 
males.     This  is  in  marked  contrast  to  the  finding  in  other  sections. 

Occupation — An  attempt  was  made  to  classify  the  cases  as  to 
previous  occupation,  but  owing  to  the  incomplete  records  forwarded 
to  the  institution  with  the  patients  and  the  long  duration  of  insanity, 
it  was  impossible  in  many  cases  to  collect  any  facts  worthy  of  record. 
Of  those  cases  showing  record  of  previous  occupation  there  were  29 
housewives,  13  farmers,  15  laborers,  one  photographer  and  one  clerk. 

Other  Diseases — Thirty-six,  or  36  per  cent.,  of  these  cases  showed 
other  organic  disease  exclusive  of  amebic  dysentery,  which,  although 
present  among  the  patients,  had  not  been  definitely  recognized. 
Among  other  organic  diseases  noted  were   12  cases  of  epilepsy,  8 


55 

cases  of  pulmonary  tuberculosis  and  12  cases  of  organic  heart 
lesions.  These  diseases  apparently  exist  in  pellagrous  patients  in 
about  the  same  proportion  as  is  found  in  the  general  population  of 
the  institution. 

Results  of  Statistics  Bearing  on  Previous  Social  Condition  of  the 
Patient — An  attempt  was  made  to  collect  data  relative  to  these 
patients,  as  to  institutional  life ;  the  use  of  corn-bread,  corn  mush, 
hominy  or  other  corn  products ;  the  quality  of  corn  used ;  the  social 
status  of  the  patients ;  and  the  occurrence,  before  commitment  to 
institutions,  of  erythema,  involving  the  backs  of  the  hands,  of  sum- 
mer diarrhoea  and  accompanying  change  in  mental  condition. 
For  this  purpose  circular  letters  were  sent  to  relatives  and  friends  of 
the  patients,  and  at  the  present  time  forty  answers  have  been 
received.  The  points  of  possible  interest  brought  out  were  about  as 
follows : 

1st.  A  large  proportion  of  the  patients  had  been  inmates  of  alms- 
houses and  asylums  for  many  years. 

2d.  A  surprisingly  small  percentage  of  the  patients  had  used  com 
products  as  an  article  of  diet  before  entering  institutions,  and  in 
none  of  the  cases  had  corn  products  continuously  been  used  as  an 
article  of  diet. 

3d.  With  two  or  three  exceptions  these  patients  were  extremely 
poor  and  had  lived  under  bad  sanitary  surroundings. 

4th.  In  only  two  cases  had  an  erythema  been  noted  on  the  back 
of  the  hands,  and  as  the  hospital  records  show  these  patients  to  have 
been  insance  16  and  23  years,  respectively,  it  is  altogether  probable 
that  these  lesions  had  no  connection  with  pellagra, 

AS  TO  THE  CLINICAL  PICTURE. 

I.  Cutaneous  Symptoms — The  skin  symptoms  were  constant  and 
characteristic  and  the  course  was  generally  as  follows :  A  bright 
red  erythematous  area  appeared  on  the  dorsum  of  both  hands,  usu- 
ally simultaneously.  Extension  occurred  within  a  few  hours,  and 
after  a  few  days  the  color  changed  to  a  purplish  red  or  reddish 
brown.  At  the  end  of  the  second  week  desquamation  began,  the 
epidermis  peeling  off  in  small,  thin,  bran-like  scales.  Desquamation 
was  usually  complete  within  a  month  of  the  first  appearance  of  the 
lesion.  The  line  of  demarcation  between  the  affected  areas  and  the 
surrounding  healthy  skin  was  distinct  and  marked.  The  dorsum  of 
the  hands  showed  involvement  in  all  cases.  Extension  of  the 
erythema  to  the  forearms  occurred  in  36  per  cent,  of  the  cases,  and 


56 

in  17  per  cent,  of  the  cases  erythematous  areas  appeared  on  other 
portions  of  the  body.  These  erythematous  areas  usually  appeared  on 
the  forehead,  the  eye-lids  and  neck.  No  characteristic  lesions  were 
noted  on  the  feet,  and  in  only  two  cases  were  such  lesions  observed 
on  the  legs.  The  palmar  surface  of  the  hands  was  not  involved, 
except  in  two  cases,  in  which  slight  extension  occurred  from  the 
dorsum  over  the  thenar  eminence.  The  so-called  characteristic 
erythematous  areas  on  the  vulva  in  the  female  were  not  noted.  In 
a  few  of  the  more  severe  cases  the  vulva  showed  marked  irritation 
and  excoriation,  but  the  lesions  were  in  no  respects  characteristic 
of  pellagra. 

Bleb  formation  occurred  in  10  per  cent,  of  the  cases.  It  was  a 
noticeable  fact  that  bleb  formation  was  always  associated  with  cases 
presenting  most  severe  symptoms  in  other  respects.  In  some  cases 
vesicles  only  were  noted,  while  in  other  cases  the  vesicles  became 
confluent,  forming  one  large  bleb.  In  66  per  cent,  of  the  cases  in 
which  bleb  formation  occurred,  death  resulted.  This  fact  would 
seem  to  have  an  important  bearing  on  the  immediate  prognosis. 

Seborrliara  has  been  referred  to  as  a  characteristic  finding.  This 
condition  was  noted  in  a  few  of  the  most  severe  cases,  but  was  by 
no  means  a  constant  or  characteristic  symptom. 

2.  Digestive  Tract  Symptoms — In  order  to  arrive  at  any  definite 
conclusions  as  to  the  significance  which  may  be  attributed  to  symp- 
toms involving  the  mouth  and  intestinal  tract,  several  factors  must 
be  considered. 

a.  The  inmates  of  this  institution  are  incapable  of  caring  for  their 
teeth,  hence,  personal  care  of  the  teeth  is  an  unknown  quantity.  It 
naturally  follows  that  particles  of  food  cling  to  the  teeth  and  become 
embedded  between  the  gums  and  roots ;  decomposition  of  these  food 
particles  occurs,  with  resulting  decay  of  the  teeth,  inflammatory 
reaction  involving  the  gums  and  buccal  mucous  membrane,  and 
the  entrance  into  the  stomach  of  these  products  of  decomposition. 
These  mouth  conditions  have  been  eliminated,  so  far  as  is  possible, 
by  the  employment  of  a  dentist.  The  following  extract  from  the 
1908  report  of  Dr.  W.  J.  Weatherwax,  dentist  for  the  institution, 
is  worthy  of  presentation:  "Many  mouths  are  a  mass  of  decayed 
teeth  and  roots,  surrounded  with  badly  inflamed  gums  with  pus 
exuding  constantly  from  pockets." 

b.  The  food  supplied  these  inmates,  while  on  a  par  with  that  sup- 
pHcd  other  institutions,— even  better  as  compared  with  some  insti- 
tutions—and beyond  criticism  as  to  quality  and  mode  of  preparation. 


57 

is  necessarily  limited  as  to  variety  and  component  constituents.  The 
resulting  difficulty  in  assimilation  with  accompanying  digestive  dis- 
orders has  a  reflex  bearing  on  any  oral  and  intestinal  symptoms 
which  may  be  present. 

Mouth — In  71  per  cent,  of  the  cases  redness  of  the  tongue  or 
buccal  mucous  membrane  was  noted.  In  general  terms  it  may  be 
said  that  there  were  no  distinct  and  characteristic  mouth  symptoms 
in  mild  cases.  In  cases  of  great  severity,  the  mouth  symptoms  were 
marked  and  characteristic.  The  tongue  was  fiery  red  and  edema- 
tous ;  the  buccal  mucous  membrane  was  intensely  inflamed.  Ulcers 
were  frequently  noted  throughout  the  mouth, — on  the  tongue  and 
buccal  mucosa, — and  excessive  secretion  of  saliva  was  of  common 
occurrence. 

In  some  cases  this  inflammatory  reaction  was  so  severe  as  to  pre- 
vent protrusion  of  the  tongue,  and  interfered  greatly  with  the  taking 
of  food.  This  severe  inflammatory  reaction  was  of  immediate  grave 
prognostic  import.  Patients  presenting  such  mouth  symptoms  sel- 
dom recovered  from  the  acute  exacerbation. 

Diarrhcea  and  Dysentery — Diarrhoea  was  present  in  85  per  cent, 
of  the  cases,  and  in  the  milder  cases  was  of  short  duration.  In  those 
cases  presenting  the  most  severe  skin  and  mouth  symptoms  the 
diarrhoea  was  severe  and  persistent.  As  will  be  shown  later,  this 
diarrhoea  may,  to  a  very  large  extent,  be  attributed  to  factors  other 
than  pellagra,  per  se.  Eighteen  per  cent,  of  these  cases  presented 
all  the  clinical  symptoms  of  dysentery — frequent  small  stools,  con- 
taining blood  and  mucous,  and  of  very  offensive  odor.  Of  those 
patients  who  died  or  who  were  rapidly  failing,  66  per  cent,  presented 
the  clinical  symptoms  of  dysentery.  In  the  more  severe  cases  it  was 
very  evident  that  some  factor,  other  than  the  causative  agents  ordi- 
narily associated  with  diarrhoea  and  dysentery,  was  present.  These 
cases  showed  a  profound  intoxication,  and  physical  failure  was 
rapid  and  marked. 

3.  Blood — Hemoglobin  averaged  81  per  cent.  The  white  cells 
averaged  9,904  and  red  cells  3,859,000,  respectively,  per  cubic  m.  m. 
During  the  acute  stage  of  the  disease  the  blood  picture  was  that  of 
anemia.  The  color  index  was  high  in  the  acute  cases.  In  23  per 
cent,  of  the  cases  the  white  cells  were  normal;  in  10  per  cent,  they 
were  below  the  normal,  and  in  Gy  per  cent,  there  was  a  leucocytosis 
of  greater  or  less  desfree. 


58 

Blood  Pressure— l^oth'mg  of  interest  or  value  was  noted  in  this 
connection.  The  Stanton  instrument  was  used,  and  the  average 
blood  pressure  was  146. 

Spinal  Tcnderness—Spiml  tenderness  was  present  in  only  14  per 
cent,  of  the  cases  and  apparently  had  no  particular  connection  with 
the  disease. 

4.  Reflexes— The  patellar  reflex  was  normal  in  only  20  per  cent, 
of  the  cases.  The  remaining  80  per  cent,  showed  a  departure  from 
the  normal,  62  per  cent,  showing  increased  reflex,  and  18  per  cent, 
showing  diminished  or  absent  reflex.  In  32  per  cent,  of  the  cases  the 
plantar  reflex  was  normal.  The  remaining  68  per  cent,  showed 
departure  from  the  normal,  53  per  cent,  showing  increase  and  15  per 
cent,  showing  diminished  reflex.  The  wrist,  elbow  and  epigastric 
reflexes  showed  nothing  worthy  of  note. 

As  some  prognostic  value  has  been  attached  to  the  Babinski  reflex 
in  connection  with  pellagra,  it  may  be  stated  that  this  reflex  was 
obtained  in  15  per  cent,  of  the  cases,  of  whom  only  20  per  cent. 
died.  As  80  per  cent,  of  the  cases  showed  abnormal  patellar  reflexes 
and  68  per  cent,  showed  abnormal  plantar  reflexes,  it  would  seem 
that  the  condition  of  these  reflexes  is  of  diagnostic  importance. 

5.  Mental  Condition — The  question  of  pellagrous  insanity  in 
connection  with  these  cases  is  entirely  a  matter  of  conjecture.  It  is 
of  interest  to  note,  hpwever,  that  within  the  past  two  years  10  per 
cent,  of  the  cases  were  committed  to  the  institution  from  civil  life. 
Four  cases  were  adjudged  insane  two  years  ago,  five  cases  one 
year  ago  and  one  case  six  months  ago.  Four  of  the  cases  in  question 
are  classified  as  dementia  praecox,  one  as  alcoholic  insanity,  one  as 
involution  psychosis,  two  as  paresis,  and  the  remainder  as  dementia 
unclassified.  Of  the  total  number  of  cases  in  this  series  50  were 
classified  as  terminal  dementia,  17  as  dementia  praecox,  5  as  manic 
depressive,  3  as  paranoia,  7  as  imbeciles,  and  the  remainder  as  vari- 
ous other  types  of  insanity.  In  57  per  cent,  of  the  cases  no  mental 
change  was  noted  during  the  acute  attack.  The  remaining  43  per 
cent,  showed  mental  change,  10  per  cent,  becoming  more  irritable 
and  excitable,  while  33  per  cent,  showed  increased  depression  or 
melancholia.  None  developed  suicidal  tendencies.  Some  of  the 
cases  in  this  scries  may  be  pellagrous  insanity. 

Ilye  Pindiugs— Dr.  Carroll  B.  Welton,  of  Peoria,  examined  the 
eyes  of  more  than  50  per  cent,  of  these  cases,  as  well  as  an  equal 
number  of  controls,  and  has  very  kindly  permitted  us  to  incorporate 
in  this  report  his  general  conclusions,  which  are  as  follows : 


59 

"Conclusions — i.  Paralysis  of  the  eye  muscles  is  found  in  the 
later  stage  of  the  disease  in  a  small  percentage  of  cases.  Conjunc- 
tivitis is  not  an  uncommon  symptom.  Early  forming  cataracts  are 
frequently  noted,  and  the  metabolic  nature  of  this  disease  is  sup- 
ported because  this  condition  is  generally  considered  as  an  altered 
state  of  the  nutrition  of  the  lens  when  occurring  in  normal  indi- 
viduals. Inflammation  of  the  optic  nerve  and  retina  is  observed  in 
a  relatively  large  percentage  of  cases.  Common  and  most  pro- 
nounced of  all  the  eye  changes  is  involvement  of  the  choroid. 

"2.  In  none  of  the  cases  presenting  eye  symptoms  could  the 
character  of  the  changes  be  regarded  as  pathognomonic  of  pellagra. 

"3.  That  the  severity  of  the  eye  symptoms  runs  parallel  with  the 
severity  of  the  general  manifestations  of  the  disease,  and  that  the 
finding  of  marked  eye  changes  adds  to  the  gravity  of  the  prognosis 
in  pellagra  and  indicates,  in  a  large  percentage  of  cases,  an  early 
fatal  termination." 

Treament — The  treatment  of  the  condition  was  discouraging. 
Thyroid  tablets  were  administered  in  a  number  of  cases  with  no 
result.  Fowler's  solution,  in  increasing  doses,  was  used  without  any 
noticeable  effect.  Atoxyl,  in  5-grain  doses,  was  used,  one  injection 
every  seven  days,  and  in  only  one  or  two  cases  could  improvement 
be  attributed  directly  to  medication.  Normal  saline  was  used  in  the 
more  severe  cases  with  only  temporary  improvement.  Bulgarian 
tablets  were  used  in  modifying  the  milk  in  the  hope  that  improve- 
ment in  intestinal  symptoms  might  result.  This  diet  had  not  been 
given  extensive  trial,  and,  while  no  definite  conclusions  were 
reached,  it  is  believed  to  be  worthy  of  further  trial. 

Mortality — Of  the  patients  making  up  this  series,  22  per  cent, 
died,  10  per  cent,  were  failing,  17  per  cent,  were  improving  and  51 
per  cent,  had  recovered  from  the  acute  attack.  It  may  conservatively 
be  estimated  that  the  death  rate  from  pellagra  at  Peoria  ranges 
between  25  and  30  per  cent. 

SUMMARY. 

1.  A  large  percentage  of  the  cases  gave  history  of  previous 
attacks. 

2.  A  large  proportion  of  the  cases  had  been  insane  for  many 
years  and  gave  histories  of  long  stay  in  institutions. 

3.  About  one-third  of  the  cases  showed  other  organic  disease, 
exclusive  of  dysentery. 


6o 

4.  All  cases  showed  cutaneous  lesions  involving  back  of  hands, 
and  in  a  number  of  cases  this  was  the  only  symptom  noted. 

5.  Bleb  formation  occurred  in  a  small  percentage  of  the  cases 
and  a  large  percentage  of  those  cases  showing  blebs  died. 

6.  Symptoms  involving  the  mouth  and  intestinal  tract  were 
characteristic  in  the  more  severe  cases  only. 

7.  The  only  reflexes  of  diagnostic  value  were  the  patellar  and 
plantar  reflexes.  These  reflexes,  in  a 'large  percentage  of  cases, 
showed  departure  from  the  normal. 

8.  A  small  percentage  of  the  cases  were  committed  to  the  insti- 
tution during  the  past  two  years  and  some  of  these  cases  may  be 
pellagrous  insanity. 

PART  II. 

The  failure  of  continental  students  of  pellagra  to  agree  on  some 
one  definite  feature  of  a  com  diet  in  relation  to  this  disease  and 
the  scepticism  of  English  writers  of  any  form  of  the  corn  theory 
force  American  observers,  in  dealing  with  a  disease,  recently  so 
widely  recognized  in  this  country,  to  undertake  to  work  out  the 
problem  for  themselves.  This  attitude  applies  to  symptomatology 
and  pathology  as  well  as  to  etiology,  because  it  is  very  evident 
that  the  most  contradictory  symptoms  and  lesions  of  concurrent 
diseases  have  been  described  as  pellagrous.  In  fact,  it  applies  to 
the  very  conception  of  the  disease  itself.  Is  pellagra  an  entity  with 
manifestations  in  the  skin,  intestinal  tract  and  nervous  system,  or 
is  it  a  symptom  complex  developing  under  certain  conditions  of  diet 
as  a  sequel  in  other  diseases? 

At  Peoria  a  start  was  made  by  the  microscopical  examination  of 
the  stools  and  a  remarkable  state  of  affairs  was  at  once  revealed. 
Control  examinations  were  then  made  of  a  number  of  non-pella- 
grous  patients  of  the  same  general  class.  For  comparison  the  results 
of  examinations  made  on  American  troops  in  the  Philippines  under 
field  conditions  are  also  given. 

Inmates  with     Non-Pellagrous  Soldiers  in 
Pellagra.  Inmates.  P,  I. 

88.  loi  454. 

Negative 14.7%  51.4%  48.8% 

Amoebae 37.5%  11.8%  16.2% 

Flagellates   (alone) 20.4%  11.8%  34-5% 

Encysted   Protozoa   (alone) 27.2%  24.4% 

Per  cent,  of  cases  with  Protozoa  85.3%  48.6%  51  2% 

The  only  ova  found  were  those  of  oxyuris  in  one  case. 


6i 

This  condition  was  considered  very  unusual  for  a  temperate 
climate,  pellagra  or  no  pellagra,  and  an  examination  of  water  was 
made.  Amoebse,  flagellates,  and  fermenting  organisms  were  found 
in  the  tap  water  at  the  asylum  on  each  of  the  three  examinations. 

The  water  comes  from  two  sources  :  First,  the  larger  part  ordi- 
narily from  an  artesian  well.  Second,  a  small  amount,  lO  to  20  per 
cent.,  from  the  city  water  supply. 

The  artesian  water  is  forced  out  by  air  pressure  from  a  depth  of 
1,800  feet  into  a  surface  tank;  it  is  then  pumped  to  an  elevated  tank 
for  distribution.  The  city  water  is  pumped  direct  to  the  elevated 
tank. 

The  artesian  water  coming  directly  from  the  pump  had  some- 
thing over  100  colonies  to  the  c.  c.  flagellates,  but  no  amoebse  or 
fermenters.  The  city  water  had  about  10  colonies  to  the  c.  c,  flag- 
ellates, but  no  amoebse  or  fermenters.  The  surface  tank  had  no 
amoebae  or  fermenters.  The  trouble  therefore  lay  in  the  pipes  and 
elevated  tank,  as  a  result  of  some  previous  contamination,  possibly 
from  the  surface  tank,  which  is  not  thoroughly  protected ;  possibly 
from  some  break  in  the  pipe  system. 

Flagellates  are  not  always  considered  pathogenic,  but  instances 
like  the  present  are  constantly  multiplying,  especially  in  the  tropics, 
and  more  and  more  suspicion  attaches  to  them.  Five  per  cent,  of  all 
the  people  examined  showed  well  marked  evidence  of  active  amoebae 
dysentery  present  in  the  mucous  and  blood  and  very  motile  amoebse. 
The  amoebae  in  the  other  cases  were  "resting." 

On  taking  up  autopsy  work  the  chain  of  evidence  in  regard  to  the 
presence  of  an  unusual  amount  of  dysentery  became  complete. 
Eighteen  autopsies  were  held  from  August  loth  to  September  20th. 
Twelve  of  these  were  done  by  ourselves,  and  of  the  18,  12,  or  66 
per  cent.,  showed  well  marked  ulcers  of  the  colon ;  two  of  the  cases 
were  as  good  specimens  of  amoebic  colitis  as  can  be  seen  in  the 
tropics ;  one  patient  with  pellagra  died  of  peritonitis  following  a 
perforation  of  an  amebic  ulcer.  These  colons  were  character- 
ized by  either  large  irregular  ulcers,  thickening  of  the  gut,  or  folli- 
cular abscesses.  Of  the  remaining  six  cases  two  had  tubercular 
ulcerations,  one  trichinosis,  the  others  follicular  enlargement  of  the 
lower  ileum  and  colon.  The  mesenteric  lymph  glands'  were  not 
materially  enlarged. 

The  autopsy  reports  are  given  in  full  in  another  place,  but  no 
other  organs  showed  any  constant  pathological  change. 


62 

In  looking  over  the  autopsy  record  for  the  last  two  years  it  was 
noticed  that  in  most  cases  the  intestines  were  not  examined;  how- 
ever, in  twelve  cases  they  were  opened,  and  in  eight  of  these  mention 
is  made  of  ulcerations  of  the  colon.  One  case  of  multiple  abscess 
of  the  liver  is  on  record. 

What  bearing,  if  any,  have  these  findings  on  pellagra?  They 
may  have  an  important  bearing  as  a  predisposing  factor  in  rendering 
tlie'  mucosa  of  the  colon  more  permeable  to  toxins  and  is  interesting 
to  note  that  Neusser  refers  to  old  and  fresh  ulcers  as  a  finding  in 
the  intestines  in  pellagra,  and  another  author  speaks  of  perfora- 
tion as  an  occasional  cause  of  death. 

The  findings  given  above  may  also  prove  to  be  worth  considering 
in  connection  with  the  seasonal  occurrence  of  the  disease. 

No  satisfactory  reason  is  known  which  would  apply  to  this 
country  except  greater  amount  of  diarrhoeal  disease  in  the  sum- 
mer months.  This  is  well  recognized  at  Peoria  and  almost  all  the 
patients  gain  weight  with  the  beginning  of  the  cold  weather.  We 
know  that  protozoa  are  more  active  during  warm  weather.  Is  it  not 
possible  that  these  protozoa  during  the  summer  months  produce 
conditions  in  the  colon  which  are  more  favorable  to  the  elaboration 
and  absorption  of  a  specific  toxin  of  pellagra? 

The  matter  of  predisposition  is  an  essential  one  as  far  as  the 
patients  at  Peoria  are  concerned,  because,  in  the  first  place,  the 
inmates  are  the  poorest  class  of  humanity  in  Illinois,  and  most  of 
the  pellagra  developed  among  the  worst  of  this  bad  class.  In  one- 
half  of  the  cases  sufficient  cause  of  death  was  found  autopsy 
and  in  one-third  of  the  living  cases  well  marked  organic  dis- 
eases other  than  senility  and  dysentery  were  present.  Almost  all 
the  cases  belong  to  the  untidy  class.  Out  of  2,100  patients  20  per 
cent,  are  constantly  untidy  and  5  per  cent,  occasionally  so.  In  many 
of  these  cases  untidiness  is  undoubtedly  synonym  for  dysentery. 

Granting  for  a  moment  that  a  protozoal  infection  of  the  colon 
is  a  predisposing  cause  of  the  majority  of  the  cases  at  Peoria,  what 
is  the  additional  fact,  or  which  gives  the  skin  symptoms,  stomatitis 
and  general  debility?  The  parasitic  theory  of  any  disease  is  the 
most  attractive  one  and  there  seems  to  be  a  strong  undercurrent  of 
feeling  in  favor  of  it  in  this  country,  but  nothing  was  seen  to  sub- 
stantiate such  an  impression  in  regard  to  cultures  from  the  blood, 
spinal  fluid  or  organs  at  autopsy.  Cultures  were  made  after  approved 
methods  (sec  appended  chart)  from  these  various  sources  in  fifteen 
cases  and  no  growths  of  any  kind  were  obtained  and  nothing  unusual 


63 

was  seen  in  fresh  or  stained  blood  films.  The  whole  picture  of  the 
disease  is  that  of  an  intoxication ;  the  gradation  from  the  slightest 
taint  of  the  most  marked  cases,  and  the  absence  of  any  constant 
finding  at  autopsy  except  in  the  intestinal  tract  point  in  this  direc- 
tion. In  this  connection  it  should  be  noted  that  while  we  have  tabu- 
lated one  hundred  cases,  many  more  undoubted  cases  kept  cropping 
out,  and  still  more  suspects  remained.  It  looked  as  if  some  common 
cause  were  at  work  on  the  whole  population,  and  the  most  susceptible 
were  affected.  This  leads  to  the  question  of  diet  and  the  overwhelm- 
ing evidence  of  some  form  of  corn  theory  among  those  most  con- 
cerned cannot  be  lightly  cast  aside.    The  possibilities  are  as  follows : 

1st.  Good  corn  is  injurious  in  large  quantities.  This  theory  can 
hardly  be  used  to  explain  the  trouble  at  Peoria,  because  the  purchases 
for  1908  show  only  thirty-eight  pounds  per  year  per  patient  received, 
or  a  little  over  one  ounce  per  day.  As  a  matter  of  fact  some  classes 
of  patients  receive  rather  more,  but  not  exceeding  two  ounces  per 
day  in  a  liberal  diet.  It  has  been  estimated  that  about  16  ounces  of 
white  rice  per  day  are  necessary  to  produce  beriberi.  If  corn  holds 
the  same  relation  to  the  disease  a  much  larger  amount  would  have 
been  necessary  at  Peoria. 

2d.  Spoiled  corn  is  responsible :  This  is  not  the  case  as  far  as 
can  be  told  by  the  senses.  The  corn  used  was  inspected  on  the 
'change  and  at  the  mill,  and  it  is  No.  2,  the  best  that  is  on  the  mar- 
ket. Nothing  in  the  way  of  a  "food  scandal"  could  be  unearthed. 
The  corn  products  do  not  have  to  be  transported  far,  and  if  any 
poisons  develop  they  cannot  be  told  by  ordinary  means. 

3d.  Toxins  may  be  developed  in  the  intestines  by  fungi  or  bac- 
teria on  a  corn  diet.  In  regard  to  moulds,  several  trials  were  made 
but  no  moulds  were  found  that  survive  the  heat  of  cooking.  Of 
course,  this  does  not  exclude  them,  but  it  makes  them  seem  less 
likely  as  a  cause.  On  the  other  hand,  a  spore-bearing  bacterium 
was  repeatedly  found  in  corn-meal,  which  survived  steaming  for 
two  hours,  and  this  seems  to  offer  possibilities. 

In  order  to  learn  something  of  parasites  on  corn,  a  trip  was  made 
to  the  University  of  Illinois,  and  it  was  found  that  only  in  recent 
years  has  any  definite  work  been  done  on  this  subject,  and  that 
much  remains  to  be  done,  especially  in  regard  to  bacteria. 

The  most  common  cause  for  disease  of  ears  on  the  stalk  has  been 
found  to  be  a  kind  of  diplodia,  which  has  been  stated  by  one  author 
to  be  on  the  increase  in  recent  years,  and  along  with  aspergillus, 
penicillium,  etc.,  has  been  advanced  as  a  cause  of  pellagra.     The 


64 

Department  of   Botany  has   agreed   to   furnish  us   cultures   of  the 
known  moulds  and  bacteria  and  work  will  be  done  with  these. 

The  most  promising  field  seems  to  be  along  the  line  of  an  intoxi- 
cation produced  by  toxins  of  corn  products  in  a  damaged  intestine, 
and  this  will  be  followed  up.  Several  instances  have  been  heard  of, 
of  a  toxic  action  for  animals,  first  of  an  excessive  corn  diet,  also  of 
a  diet  of  corn  gluten  infected  with  moulds;  and  there  are  no  doubt 
several  kinds  of  disease  connected  in  some  way  with  corn,  but 
pellagra  must  be  due  to  one,  not  to  several  kinds  of  corn  poisoning. 

The  outstanding  fact  about  corn  raising  in  the  last  fifteen  years 
is  that  the  shelled  corn  is  marketed  four  to  eight  weeks  earlier  than 
it  used  to  be,  that  the  time  of  weathering  and  drying  on  the  stalk 
is  cut  short  and  that  more  trouble  is  experienced  in  handling  the 
corn  and  preventing  it  from  going  bad.  This  fact,  with  the  con- 
siderable increase  of  the  use  of  corn  products  in  the  past  few  years 
may  prove  to  be  of  significance. 

The  recommendations  respectfully  submitted  for  the  Peoria  State 
Hospital  are : 

1st.  Cleaning  out  the  pipes  of  the  cold  water  supply ;  better  pro- 
tection of  the  surface  tank ;  regular  examinations  of  the  water  for 
bacteria  and  protozoa. 

2d.  Examination  of  stools  of  possible  cases  of  dysentery,  especi- 
ally among  the  untidy,  and  appropriate  treatment  of  dysentery 
cases. 

3d.  Examination  of  corn  from  the  diet  of  the  more  debilitated 
patients. 

SUMMARY. 

1.  The  pellagrous  patients  at  the  Peoria  State  Hospital  show  a 
very  high  percentage  of  protozoal  infections  of  the  colon. 

2.  A  study  of  the  patients  and  diet  points  to  some  endogenous 
intoxication. 

3.  The  protozoa  may  play  an  important  predisposing  part  in  the 
seasonal  production  and  absorption  of  an  endogenous  toxin. 


DISCUSSION  ON  THE  PAPERS  OF  DRS.  ZELLER,  SILER 

AND  NICHOLS 
Dr.  L.  J.  Pollock,  Dunning,  Illinois :    The  discovery  of  pellagra 
in  the  State  of  Illinois  is  indicative  of  its  widely  spread  distribution 
in  the  United  States.     The  importance  of  its  recognition  in  other 
States  than  those  of  the  South  is  self-evident. 


65 

The  first  case  occurring  in  the  Cook  County  Institutions  was 
noted  in  August,  1908,  when  the  diagnosis  was  as  yet  not  made. 
With  the  subsequent  occurrence  of  three  other  cases  presenting  the 
same  symptomatology,  course  and  fatal  outcome,  and  not  being 
familiar  with  the  occurrence  of  pellagra  in  the  United  States,  we 
came  to  the  conclusion  that  we  were  dealing  with  a  clearly  defined 
disease  with  which  we  were  unfamiliar.  A  clue  as  to  its  nature  was 
offered  to  us  in  the  description  of  pellagrous  insanity  in  Bianchi's 
Psychiatry.  From  the  onset  the  next  case  was  thought  to  follow 
closely  the  description  of  Italian  pellagra,  but  it  was  not  until  the 
inquiry  of  the  South  Carolina  State  Board  of  Health  was  addressed 
to  us  that  the  diagnosis  of  pellagra  was  definitely  made.  The  first 
public  notice  of  the  occurrence  of  pellagra  in  the  Cook  County  Insti- 
tutions followed  the  confirmation  of  our  diagnosis  by  Dr.  C.  H. 
Lavinder  on  July  18,  1909. 

The  devious  route  at  which  we  came  to  the  conclusion  that  we 
were  dealing  with  pellagra  proclaims  the  necessity  for  widely  dis- 
tributing literature  concerning  the  nature  and  prevalence  of  this 
condition  throughout  the  United  States.  This  importance  is  further 
emphasized  by  the  fact  that  pellagra  has  existed  in  the  Illinois  insti- 
tutions for  a  number  of  years  before  its  recognition,  Dr.  Podstata, 
Superintendent  of  the  Northern  Hospital  for  Insane,  recalling  cases 
occurring  in  his  service  several  years  ago. 

A  description  of  pellagra  is  superfluous  following  the  numerous 
reports  upon  this  subject,  but  the  various  modes  of  onset  and  mul- 
tiplicity of  symptoms  justify  a  brief  analysis  of  the  cases  arising  at 
the  Cook  County  Institutions. 

The  entire  number  was  26.  Females  13;  all  insane;  males,  13; 
8  insane,  2  in  the  poor  house  and  2  in  the  hospital  for  tuberculosis. 

The  duration  of  the  fatal  cases  averaged  thirty-four  days.  The 
duration  in  the  remaining  cases  averaged  forty  days. 

The  nativity  was  as  follows :  United  States,  7 ;  England,  i ;  Ire- 
land, 9 ;  Bulgaria,  i ;  Germany,  5 ;  Denmark,  i ;  Austria,  i ; 
unknown,  i. 

Of  those  foreign,  the  Bulgarian  was  in  this  country  six  months, 
the  others  ranged  from  eight  to  forty  years.  They  had  been  con- 
fined in  the  institution  from  four  months  to  twelve  years. 

The  psychoses  at  the  time  of  admission  were  as  follows :  De- 
mentia paralytica,  4 ;  alcoholic,  5 ;  dementia  precox,  5 ;  paranoia,  3 ; 
acute  confusional,  i ;  melancholia,  i ;  senile  dementia,  3. 

The  symptomatology  has  been  in  general  fairly  uniform.     The 

5— p.  c. 


66 

cases  had  variable  onsets,  some  with  malaise,  mental  depression  and 
indifference;  others  with  anorexia,  nausea  and  vomiting,  increasing 
weakness,  dizziness  and  staggering  gait;  all  presenting  a  dermatitis, 
usually  symmetrical  in  distribution.  In  some,  however,  one  extrem- 
ity became  affected  before  the  other.  The  lesion  commenced  in  the 
majority  of  cases  as  a  hardened  erythematous  condition,  becoming 
pigmented,  fissuring  and  finally  desquamating,  leaving  an  atrophic 
skin  behind ;  in  the  others  the  onset  of  the  dermititis  was  sudden,  with 
the  formation  of  blebs,  which,  when  burst,  left  the  underlying  por- 
tion of  the  skin  moist,  pink  and  glazed.  The  exposed  portions  of  the 
body  were  usually  attacked,  but  in  some  few  cases  the  ankles  and 
knees  and  in  one  case  the  buttocks  were  affected ;  one  case  is  prom- 
inent on  account  of  the  wide  distribution  of  the  dermatitis  and  the 
large  involvem.ent  of  the  anterior  surface  of  the  arm.  In  this  case 
there  was  a  dermatitis  of  the  anterior  and  posterior  surface  of  the 
lower  one-third  of  the  forearm,  the  dorsum  of  the  hands,  a  symmet- 
rical area  on  the  anterior  surfaces  of  both  elbows,  both  knees,  the 
popliteal  spaces  and  ankles.  The  mucous  membranes  showed 
changes,  in  the  mouth  as  a  severe  stomatitis,  with  numerous  ulcers 
and  heaped  up  epithelium ;  in  some  cases  a  conjunctivitis,  and  in  the 
majority  of  women  affected  a  vaginitis  was  present.  The  gastro- 
intestinal system  showed  stomatitis,  denuded  tongue,  marked 
ptyalism ;  in  some  cases  anorexia  and  refusal  to  eat,  vomiting  and 
severe  diarrhoea,  associated  with  tenderness  over  the  abdomen.  The 
stools  were  lienteric  and  contained  small  quantities  of  blood.  The 
nervous  system  showed  weakness,  staggering  gait,  dizziness,  exag- 
gerated knee  jerks,  followed  by  their  disappearance,  choreiform 
movements  and  in  one  case  symptoms  of  meningitis,  as  shown  by 
marked  spasticity,  a  double  knee  and  ankle  clonus,  Gordon  Oppen- 
heim  and  Kernig's  sign,  the  patient  dying  of  respiratory  failure. 
The  mental  state  has  been  one  of  depression,  occurring  upon  the 
former  mental  condition,  bordering  upon  melancholia  with  crying, 
refusal  to  eat,  etc.  In  one  case,  with  the  subsidence  of  the  skin 
lesion,  the  patient  entered  into  an  excited,  clouded,  delirious  condi- 
tion in  which  she  has  since  remained. 

The  course  in  those  cases  not  dying  during  the  acute  exacerbation 
has  been  one  of  uniformly  progressing  cachexia  and  weakness,  and 
despite  the  disappearance  of  the  gastrointestinal  lesions  and  skin  dis- 
turbance, the  patients  progressively  became  weaker  and  died. 

Of  those  cases  which  died,  numbering  14,  i  died  of  apoplectiform 
convulsions  of  dementia  paralytica;  one  in  a  low  muttering  delirium 


with  choreiform  movements ;  one  of  respiratory  failure ;  two  of 
tuberculosis;  one  of  carcinoma  of  the  stomach;  and  the  others  of 
exhaustion. 

The  medicinal  treatment  has  consisted  of  the  hypodermic  adminis- 
tration of  arsenic  salts,  with  no  appreciable  effect. 

The  pathology  as  seen  in  the  post-mortem  examinations  upon  four 
cases  showed  nothing  distinctive.  Besides  the  findings  of  cachexia, 
some  fatty  degeneration  of  the  liver,  kidney  and  heart,  injection  of 
the  large  intestines,  prominent  Peyer's  patches,  showing  shaven 
beard  appearance  near  the  ileo-cecal  valve  and  enlargement  of  the 
mesenteric  glands  were  present.  In  the  nervous  system  some  edema 
of  the  meninges  and  microscopically  chromatolysis  of  the  anterior 
horncells  of  the  cord. 

Dr.  C.  H.  Lavinder^  Washington,  D.  C. :  I  had  the  pleasure  of 
going  to  Peoria,  Illinois,  when  pellagra  first  developed  there.  So 
far  as  the  symptomatology  of  the  disease  in  Peoria  is  concerned,  I 
think  it  is  very  wise  for  all  of  us  to  tabulate  symptoms,  for  it  is  the 
accepted  opinion  that  pellagra  varies  in  various  sections  of  the 
country  and  in  various  seasons  of  the  same  sections  of  the  country; 
that  is  to  say,  some  particular  phenomena  will  be  prominent  in  one 
season  or  section  which  may  not  appear  in  other  seasons  or  sections. 

So  far  as  Captain  Nichols'  paper  is  concerned,  working  in  Colum- 
bia with  Dr.  Babcock,  I  myself  have  found  protozoa  in  the  stools  of 
pellagrins,  but  not  so  frequently  as  he  has  found  them.  I  think  it  is 
an  interesting  observation.  The  plagellated  organisms  which  I  saw 
are  considered  non-pathogenic. 

Dr.  J.  W.  MoBLEY,  Milledgeville,  Georgia :  I  wish  to  make  a  few 
remarks  in  connection  with  Dr.  Nichols'  paper  as  regards  the  fre- 
quent complication  of  enteric  ulcer  of  some  character  associated 
with  pellagra. 

In  looking  over  the  pathological  record  at  the  Georgia  State  Sani- 
tarium, covering  possibly  loo  cases,  more  or  less,  away  back  as  far 
as  1897,  according  to  the  descriptions  of  the  post-mortem  examina- 
tions made,  there  were  cases  in  which  there  was  pigmentation  of  the 
hands  and  feet,  skin  abrasions,  and  stomatitis.  Of  course,  these  cases 
were  not  considered  at  that  time  pellagrous  in  character.  I  made 
many  of  these  post-mortems  myself,  and  the  fact  prevailed  that 
ulcers  frequently  appeared  about  the  ileum  in  those  cases  which  now, 
I  have  every  reason  to  believe,  were  pellagrous.    Furthermore,  there 


68 

was  an  increase  of  intestinal  parasites.  Dr.  Willetts,  recent  path- 
ologist to  the  Georgia  State  Sanitarium,  in  500  unselected  cases  for 
examination,  found  in  the  feces  about  57  per  cent,  of  infections  with 
some  form  of  intestinal  parasite,  and  it  is  noteworthy  that  of  these 
500  cases  35  were  pellagrous.  Of  the  pellagrous  cases,  there  were 
about  40  per  cent,  infections  with  intestinal  parasites ;  the  most 
important  v/ere  infections  from  the  strongoloides,  and  uncinaria, 
both  being  bloodsuckers,  and  especially  strongoloides,  which  was 
found  in  20  per  cent,  of  the  cases,  and  which  is  the  hardest  parasite 
to  dislodge  from  the  intestinal  mucosa.  I  have  been  connected  with 
this  institution  twelve  years,  and  in  going  back  over  the  records  I 
can  recall  these  cases  as  pellagrous  quite  frequently.  Just  at  this 
point  I  want  to  speak  of  two  particular  conditions,  which  are  almost 
the  same,  and  yet  there  is  a  little  difference  in  them.  It  is  in  this 
relation  that  we  are  often  perplexed  to  know  whether  we  have  a 
nervous  disease  primary  to  pellagra,  6r  whether  the  pellagra  is 
primary,  and  the  nervous  symptoms,  being  trophic  in  character,  are 
secondary.  About  five  months  ago  a  young  lady  was  admitted  to 
our  institution,  who  gave  a  history  of  epilepsy,  with  organic  brain 
disease,  dating  from  the  age  of  3  years.  She  had  convulsions.  These 
convulsions  were  frequent,  and  after  about  three  months  it  was 
noted  that  there  was  some  stupor.  She  was  not  profoundly  stupid. 
While  she  was  epileptic — and  these  patients  are  usually  dull  men- 
tally— yet  her  expression  was  bright.  She  had  some  scanning 
speech.  The  reflexes  were  all  exaggerated.  In  a  general  way,  she 
had  all  the  symptoms  of  cerebro-spinal  sclerosis.  She  became  some- 
what stuperous,  finally  developed  stomatitis  with  an  aphthous  deposit 
around  the  margins  of  the  tongue.  The  inflammation  extended,  after 
which  she  became  more  stupid.  She  was  moved  to  the  infirmary, 
and  developed  a  mild  diarrhoea.  This  case  represents  the  active  type 
of  intoxication  psychosis  to  which  I  wish  to  call  your  attention,  and 
this  woman  died  in  four  weeks  after  her  removal  to  the  infirmary. 
She  had  a  temperature  the  first  week  which  was  below  normal.  The 
second  week  the  temperature  became  a  little  elevated,  while  in  the 
third  week  it  rose  to  105.  The  skin  eruption  began  to  appear  at 
about  the  end  of  the  third  week.  It  was  not  pronounced  in  character, 
but  simply  a  brownish  red  pigmentation  about  the  hands  and  about 
the  mouth.  She  then  developed  all  the  symptoms  apparently  of 
spinal  trouble,  dying  almost  in  a  condition  of  leptomeningitis. 

Here  we  have  a  case  of  progressive  organic  disease  of  the  brain 
and  spinal  cord  concluding  with  such  symptoms  as  give  us  every 


69 

reason  to  suspect  an  acute  and  profound  intoxication  of  pellagrous 
origin.  On  the  contrary,  it  would  not  be  entirely  out  of  place  to 
regard  the  stomatitis  as  coincident,  and  the  trophic  disturbance  about 
the  hands  and  feet  as  secondary  to  the  organic  nervous  disease,  in 
which  pellagra  played  no  part  in  the  etiology. 

Case  No.  i  : 

Miss  L.,  white  female;  age  30;  admitted  March  4,  1909;  native  of 
Indiana;  resident  of  Georgia  one  and  one-half  years.  Family  and 
personal  history  free  from  syphilis,  insanity,  pellagra  and  tubercu- 
losis, though  patient  had  some  remote  physical  signs  of  tuberculosis 
on  entrance  examination ;  very  well  nourished ;  gait  spastic ;  marked 
inco-ordination ;  some  intention  tremors ;  speech  scanning ;  marked 
mental  reduction.  Convulsion  since  child  three  years  old.  Patella 
reflex  exaggerated ;  Babinski  and  Gordon  absent ;  some  clonus. 
Patient  imperfectly  oriented  as  to  time,  place  or  person;  attention 
poor;  some  anesthesia  and  atrophy  of  lower  extremity.  Voluntary 
grasp  quite  deficient.  While  the  patient's  mentality  was  very  limited, 
the  expression  was  cheerful  and  eye  rather  bright.  The  first  known 
pellagrous  symptoms  developed  about  four  weeks  before  death ;  there 
was  some  stupor,  with  increased  saliva,  the  patient  was  disposed  at 
this  time  to  hold  food  in  the  mouth — a  mild  stomatitis  gradually 
came  on,  some  apparent  increase  in  the  tremor.  The  sore  mouth 
increased  with  aphthous  deposits  about  the  margins  of  the  tongue. 
Deep  reflexes  generally  increased ;  no  hallucinosis.  Diarrhoea  set  in 
one  week  from  first  symptom — five  to  ten  offensive  stools  daily; 
acid  in  reaction ;  dark  brown  color ;  temperature  98  to  99  F.  during 
first  week.  This  represents  the  morbid  picture  for  about  two  weeks, 
when  all  symptoms  increased  in  activity  with  temperature  103  F. 
A  dark  reddish  pigmentation  developed  about  the  dorsal  surfaces  of 
both  hands,  with  a  few  discrete  areas  about  the  mouth.  The  tem- 
perature gradually  rose  to  105  F. ;  pulse  120 — the  entire  morbid 
cycle  covering  something  over  three  weeks,  when  the  patient  died 
in  a  spastic  state  quite  similar  to  lepto-meningitis.  This  case  also 
represents,  in  its  relation  to  insanity,  an  acute  intoxication  psychosis, 
with  a  fulminating  conclusion.  First  heading  mental  classification; 
Acute  Intoxication  Psychosis. 

Case  No.  2: 

Mrs.  H.,  white  female;  age  23  years;  native  Carolinian;  resident 
in  country  up  to  several  years  ago,  since  which  time  she  has  lived  in 
city;  admitted  into  sanitarium  February  4,  1909.     Family  and  per- 


70 

sonal  history  negative  as  to  insanity,  tuberculosis,  syphilis,  sprue  or 
pellagra.  Since  marriage  the  patient  has  been  operated  on  for  appen- 
dicitis and  has  shown  some  hysterical  tendency  from  time  to  time. 
The  first  evidence  of  mental  disturbance  was  shown  about  one  week 
before  admission  to  State  Sanitarium,  when  the  patient  expressed 
some  apprehensive  hallucinosis,  with  slight  mental  confusion.  She 
was  supposed  to  be  suffering  from  neurasthenia,  and  was  sent  to  a 
general  hospital.  Her  condition  grew  steadily  worse,  so  she  was 
committed  to  the  State  Sanitarium.  At  time  of  reception  patient  was 
poorly  nourished;  mental  confusion  marked;  disoriented  as  to  time, 
place  and  person.  Attention  very  poor ;  insight  lost.  By  the  second 
day  after  admission  patient  had  developed  a  mild  delirium,  and  fur- 
ther tests  to  determine  the  psychic  reaction  were  inapplicable.  She 
was  now  in  a  state  of  active  hallucinosis,  with  a  psycho-motor  reac- 
tion indicative  of  fear  and  impending  danger.  The  gait  was  spastic ; 
patella  reflex  exaggerated ;  Babinski  inconstant ;  ankle  clonus  marked 
in  both.  Some  apparent  hyperasthesia.  There  was  no  evidence  of 
skin  disturbance  up  to  this  time.  There  was  a  slight  stomatitis,  with 
whitish  deposits  around  margin  of  tongue.  Stools  liquid  and  while 
infrequent  at  first,  an  uncontrollable  diarrhoea  finally  developed. 
Temperature  for  first  week  97  to  99  F. ;  pulse  90  on  average.  Sore 
mouth  gradually  grew  worse  with  all  symptoms  increasing  in  inten- 
sity ;  temperature  during  this  exacerbation  goes  to  104  F,  Following 
this  there  was  a  remission  of  acute  character  of  all  symptoms,  the 
patient  dying  after  about  six  weeks  from  exhaustion.  A  reddish 
brown  pigmentation  appeared  on  dorsal  surfaces  of  hands  about  the 
fourth  week  of  the  disease;  some  discoloration  about  the  mouth. 
The  last  phase  of  the  disease  presenting  the  physical  signs  of  amyo- 
trophic lateral  sclerosis. 

The  mental  aspect  of  the  disease  is  indicative  of  a  profound 
Infective  Exhaustion  Psychosis ;  or  the  second  classification  we  have 
already  referred  to. 

Dr.  J.  W.  Babcock,  Columbia,  South  Carolina:  I  have  not  the 
honor  and  pleasure  of  a  personal  acquaintance  with  Dr.  Zeller,  but 
I  think  Dr.  Zeller,  like  all  asylum  doctors,  including  myself,  is  here 
absolutely  in  the  interest  of  truth.  I  do  not  think  Dr.  Zeller  or 
myself  represents  any  peculiar  school,  as  to  the  theory  of  the  devel- 
opment of  pellagra.  We  are  all  here  to  learn  the  truth,  and  to  confer 
together  in  the  interest  of  truth.  This  subject  has  been  forced  upon 
the  attention  of  the  public  through  the  often  maligned  asylum  and 


71 

the  asylum  doctor,  and  as  far  back  as  twenty-five  years  ago  we  were 
asked  by  so  great  a  light  as  Weir  Mitchell  what  contribution  had  the 
asylum  doctors  made  towards  the  progress  of  medical  science  ?  So  I 
want  to  ask  this  assembly  in  which  the  minority  is  largely  composed 
of  asylum  men  to  recognize  that  out  of  these  asylums  comes  this 
momentous  question.     (Applause.) 

Again,  in  behalf  of  the  asylum  doctor,  and  it  has  been  my  pleasure 
to  serve  as  a  private  in  the  ranks  with  men  for  twenty-five  years, 
whose  position  is  like  nothing  else  on  earth,  I  will  say  that  there  are 
some  men  whose  prime  characteristic  is  moral  courage.  In  all  my 
experience  with  asylum  doctors,  I  have  known  of  no  one  of  them 
who  has  shown  the  high  degree  of  moral  courage  that  Dr.  Zeller  has 
in  reading  his  paper  from  this  platform  this  afternoon,  and  if  I 
may  presume  on  this  occasion  to  thank  Dr.  Zeller  personally  and  in 
behalf  of  asylum  doctors  throughout  the  length  and  breadth  of  the 
United  States,  then  I  want  to  return  our  humble  thanks  to  him  for 
standing  here  in  South  Carolina  and  reading  us  that  magnificent 
paper.  (Applause.)  I  know  many  asylum  men,  but  I  know  not  a 
single  one  in  America  or  in  Europe  who  would  come  before  an 
audience  like  this  and  stand  before  the  people  of  the  United  States 
and  proclaim  in  the  manner  he  has  done  here  this  afternoon  what  he 
believes  to  be  the  truth.     (Applause.) 

Dr.  Julius  C.  Sosnowski,  Charleston,  South  Carolina:  I  was 
struck  with  the  ages  of  the  patients  mentioned  by  Dr.  Zeller,  Dr. 
Nichols  and  by  Dr.  Siler.  The  average  age  seems  to  be  50  for  the 
older  patients,  and  the  youngest  in  the  thirties.  While  I  have  seen 
very  few  cases  of  pellagra,  yet  I  recall  twelve  that  came  under 
my  observation  in  Charleston,  and  of  this  number  six  were  below 
14  years  of  age;  one  was  18;  four  were  between  20  and  40,  and  one 
was  above  40.  Six  of  these  patients  were  white  and  six  colored. 
The  ages  of  these  patients  would  seem  to  be  at  variance  from  the 
experience  of  those  who  have  already  spoken. 

Dr.  M.  B.  Young,  Rock  Hill,  South  Carolina :  Speaking  of  the 
ages  of  patients  afflicted  with  pellagra,  I  recall  one  case  of  a  little 
child,  two  years  and  five  months  old,  in  which  I  made  a  diagnosis  of 
this  disease,  which  was  confirmed  by  my  professional  colleagues, 
who  saw  the  case  in  consultation.  This  child  developed  a  rash  on 
the  backs  of  the  hands  and  on  the  feet.  The  child  was  accustomed  to 
playing  with  scouring  soap,  and  the  mother  thought  the  dermatitis 


72 

was  produced  by  the  child  lathering  itself  with  this  soap.  She  did  not 
call  my  attention  to  the  rash  at  the  time  I  first  saw  the  child.  The 
child  went  on  for  a  month  or  two,  when  the  red  rash  disappeared, 
and  the  skin  became  crusty  and  began  to  peel  off.  The  child  devel- 
oped temperature.  Very  little  attention  was  paid  to  the  rash,  which 
appeared  on  the  hands.  I  dismissed  the  case  for  a  while,  until  I  was 
sent  for  again,  when  the  child  developed  diarrhoea.  The  stools  were 
of  a  muco-bloody  character.  This  continued  for  one  or  two  days 
until  the  stools  became  very  bloody.  The  child  was  demented,  and  it 
sometimes  required  two  or  three  in  the  room  to  hold  it  in  bed.  The 
child  became  so  weak  that  it  could  not  get  out  of  bed.  At  about  this 
time  I  had  an  acute  attack  of  malaria  and  left  the  case  in  the  hands 
of  another  practitioner.  Not  having  read  what  Dr.  Nichols  has  said 
about  amoebae  at  the  time,  I  did  not  think  of  them,  although  Dr. 
Miller,  who  saw  the  case,  and  myself,  spent  hours  in  looking  for 
amoebae  in  other  cases  that  were  known  at  the  time  to  be  pellagrous. 

Dr.  H.  E.  Menage,  New  Orleans,  Louisiana:  We  have  had  in 
one  of  the  wards  of  our  hospital  the  case  of  a  little  girl  in  whom 
the  disease  was  typical.  The  child  lived  for  a  week  after  we  first 
saw  it.  There  was  a  previous  history  of  two  years'  duration  of  the 
disease.  The  interesting  features  about  the  case  are  the  pathologic 
findings  in  the  brain.    The  child  was  idiotic  and  cried  constantly. 

Upon  opening  the  skull  cavity  the  brain  presented  a  peculiar 
appearance.  The  anterior  convolution  was  large  and  edematous. 
The  posterior  convolution  behind  the  fissure  of  Rolando  was  small 
and  vermiform,  in  that  it  looked  like  a  bundle  of  worms.  On  either 
side  of  the  middle  of  the  main  comissure  and  just  back  of  the  fissure 
of  Rolando,  bilaterally  and  symmetrically,  there  were  two  large 
cysts  filled  with  a  fluid  and  encapsulated  with  rather  thick  walls. 

I  thought  I  would  mention  this  case  because  it  is  not  reported  in 
the  paper  which  I  shall  read  for  Dr.  Dyer. 

Dr.  John  N.  Thomas,  Pineville,  Louisiana :  I  want  to  ask  Dr. 
Zeller  what  part  corn  bread  played  in  his  dietary  at  the  institution  in 
Peoria,  and  how  much  corn  bread  he  gave  his  patients. 

Dr.  Zeller  :  Corn  bread  constitutes  a  very  insignificant  portion 
of  our  diet.  About  two  ounces  a  day  is  given  on  an  average  to  all 
patients,  so  that  corn  is  not  a  great  factor  in  our  diet. 


73 

Dr.  Thomas  (resuming)  :  My  experience  is  almost  similar  to 
that  of  Dr.  Zeller's,  except  that  at  our  dinner  meal  the  only  bread 
used  is  made  from  corn  meal  and  the  patients  are  given  it  liberally. 

Since  the  papers  and  investigations  of  Drs.  Babcock  and  Lavinder, 
I  have  been  so  thoroughly  convinced  that  corn  bread  plays  a  very 
important  part  in  the  causation  of  this  disease,  that  T  have  eliminated 
it  entirely  from  our  list  of  eatables  at  the  Louisiana  Hospital  for 
Insane. 

The  cases  presented  for  examination  seem  to  be  mostly  chronic 
cases,  and  judging  from  the  pictures  shown  and  the  cases  we  have 
seen,  none  of  them  seem  to  be  mild,  but  are  chronic  cases  that  have 
existed  for  three  or  four  years.  If  it  is  possible  it  would  be  well  to 
exhibit  a  few  mild  cases. 

As  to  the  water  supply  and  suspicion  of  bacterial  infection  of  the 
Insane  Hospital  at  Peoria,  I  wish  to  say  that  we  receive  our  water 
supply  from  an  artesian  well  over  i,ioo  feet  deep,  and  the  water  has 
been  passed  upon  by  a  chemist  as  being  absolutely  pure,  so  that  we 
have  eliminated  that  feature  as  a  possible  cause  of  the  disease.  Our 
food  supply  is  liberal  in  amount,  and  we  can  ascribe  the  disease  to 
nothing  else  but  bad  corn  meal. 

I  have  seen  cases  of  pellagra  develop  in  patients  who  have  never 
been  off  the  ward  at  all,  and  I  am  convinced  that  the  disease  is  either 
due  to  impure  corn  meal  or  to  an  infection  of  some  kind. 

Dr.  George  A.  Zeller,  Peoria,  Illinois  :  The  water  supply  of  our 
institution  is  derived  from  the  city  mains  of  Peoria.  It  enters  a  clean 
cistern  or  reservoir  from  which  it  is  pumped  into  circulation.  The 
anomaly  of  the  situation  is  that  there  are  300  employees  who  drink 
this  water  all  the  year  around,  and  have  done  so  since  the  institution 
was  founded,  yet  there  has  never  been  a  case  of  dysentery  in  any 
employee  of  the  institution.  There  has  been  no  case  of  diarrhoea  in 
our  institution  among  the  employees.  When  we  come  to  take  up  the 
question  of  the  water  supply,  and  remember  that  our  employees  are 
healthy  and  vigorous  and  are  absolutely  free  from  any  intestinal 
disease  traceable  to  the  water,  and  then  add  to  that  the  1,800  or  2,000 
patients  in  the  institution  who  have  no  diarrhoea  the  year  around, 
these  things  of  themselves  invalidate  somewhat  the  theory  of  a 
polluted  water  supply.  It  is  true,  amoebae  have  been  found  in  the 
water,  but  I  have  some  ideas  about  that  which  I  will  not  give  you 
at  this  time.  Dr.  Buhlig  made  several  analysis  of  our  water  and 
also  found  amoebae  and  flagellates,  but  he  says  that  such  a  condition 


74 

is  not  unusual,  and  I  rather  gained  the  impression  from  him  that 
Chicago  water  does  not  taste  good  unless  it  has  a  few  amcebse  in  it. 
I  would  like  to  hear  from  Dr.  Buhlig  on  the  subject. 

Dr.  I.  W.  Faison,  Charlotte,  North  Carolina:  In  the  first  place 
I  want  to  sanction  and  endorse  what  Dr.  Babcock  has  said  m  behalf 
of  Dr.  Zeller.  I  want  to  say  to  him  that  as  a  Northern  man  he  is 
almost  good  enough  to  come  South  to  live.  (Laughter.)  The 
cases  of  pellagra  that  have  come  under  my  observation  have  been 
acute.  Those  I  have  seen  have  had  no  skin  lesions  at  all,  and  I  am 
fully  persuaded  that  these  cases  can  occur  and  do  occur  as  pellagra 
without  any  skin  lesions  whatever. 

I  recall  the  case  of  an  old  maid  (I  do  not  care  to  give  her  name), 
who  was  taken  sick  three  or  four  years  ago.  She  remained  under 
my  care  and  observation  without  a  diagnosis  of  pellagra  having  been 
made  until  the  spring  of  this  year.  She  only  had  a  nervous  indiges- 
tion, and  nervous  trouble,  or  weakness,  without  any  manifestations 
of  the  disease  which  would  enable  me  to  make  a  diagnosis  of  pel- 
lagra. She  had  an  acute  stomatitis,  with  a  very  red  flannel-like 
tongue.  There  were  blebs  over  the  mucous  membrane  of  the  lips 
and  tongue  in  her  case.  In  the  other  cases  I  have  seen  the  tongue 
was  a  clean  red,  but  in  this  case  there  was  an  immense  crop  of 
blebs.  She  had  considerable  pain  from  the  condition  about  the 
mouth.  Salivation  was  terrific,  and  the  odor  which  came  from  her 
mouth  was  almost  unbearable.  She  had  intense  diarrhoea;  the 
mucous  membrane  of  the  rectum  was  greatly  inflamed,  and  she  had 
what  I  might  call  a  fiery  red  mucous  membrane  all  over  the  vulva 
and  vagina.  With  this  stomatitis  and  salivation,  as  much  as  three 
quarts  of  saliva  came  from  her  mouth  in  24  hours.  From  a 
woman  who  had  weighed  98  or  95  pounds  she  ran  down  to  80 
pounds.  She  became  very  weak  and  had  to  be  confined  to 
bed.  At  present,  to  all  intents  and  purposes,  this  woman 
is  in  better  condition  than  she  has  been  for  the  past  ten  years. 
She  has  increased  in  weight  from  80  pounds  to  no,  weighing 
more  than  she  ever  weighed  before  in  her  life.  The  stomatitis 
was  painful,  and  nothing  that  I  ever  did  to  her  afforded 
any  relief  except  a  solution  of  argyrol,  10  grains  to  the  ounce.  I 
washed  out  her  month  with  peroxide  of  hydrogen,  followed  by 
boracic  acid  solution,  and  by  argyrol  every  three  hours.  The  argyrol 
in  this  case  relieved  the  pain  in  her  mouth  like  magic.  In  a  few 
days  the  blebs  began  to  shrink.  There  was  no  pus.  They  fell  off 
like  old  vaccinated  scars,  leaving  a  healthy  mucous  membrane.    This 


75 

woman  had  false  teeth,  and  yet  under  the  plate  that  carried  the  false 
teeth  redness  did  not  appear.  When  we  took  out  the  plate  and  exam- 
ined the  condition  of  the  mouth  we  found  an  absolutely  normal  color 
of  the  mucous  membrane ;  but  behind  the  plate  and  inside  of  the 
cheek  the  mucous  membrane  in  different  portions  of  the  mouth 
showed  this  fiery  redness.  In  addition  to  the  use  of  argyrol,  I  gave 
her  hypodermically  every  day  two-thirds  of  a  grain  of  atoxyl  and 
1-30  gr.  strychnine  three  times  a  day.  I  kept  this  up  for  three  weeks, 
and  with  it  cut  out  the  use  of  all  corn  bread.  She  showed  remark- 
able improvement. 

I  came  here  last  year  persuaded  that  corn  was  the  cause  of  pel- 
lagra. I  left  very  much  in  doubt  on  this  point.  I  stand  here  today 
and  say  that  my  opinion  is  that  corn  products  furnishes  the  cause; 
next  year  may  be  so  changed  that  corn  is  not  the  cause  of  this 
disease.  Of  course,  I  reserve  the  right  to  change  my  mind  as  to  the 
cause  of  this  disease.  In  my  opinion  there  is  some  condition  in 
corn  meal  or  in  corn  bread  which  acts  as  the  exciting  cause  of  pel- 
lagra, and  what  that  condition  is  we  do  not  know,  and  when  these 
men  across  the  water,  who  have  studied  the  disease  for  years  and 
years,  say  that  the  disease  is  produced  by  damaged  corn  or  maize, 
we  should  not  be  easily  led  away  from  that  idea. 

In  the  treatment  of  the  case  I  have  referred  to  I  neglected  to  say 
that  I  flushed  out  daily  the  colon  with  normal  salt  solution,  and  I 
must  say  it  was  one  of  the  best  remedies  I  used.  I  followed  the 
treatment  I  have  outlined  for  four  or  five  weeks,  when  the  redness 
of  the  mouth  disappeared ;  the  blebs  gave  way ;  the  patient's  appetite 
returned,  and  the  woman  felt  so  good  that  I  woke  up  to  the  fact  that 
I  had  gone  far  enough  and  was  afraid  to  use  atoxyl  further.  Accord- 
ingly, I  stopped  its  use,  but  in  ten  days  after  I  stopped  its  use  the 
mouth  became  inflamed  again.  I  again  began  the  use  of  atoxyl,  and 
in  five  days  improvement  began  and  continued.  I  kept  her  on  it. 
She  then  went  to  the  mountain  country,  is  now  able  to  walk  about, 
her  cheeks  are  taking  on  the  glow  of  youth,  and  she  is  a  healthy 
woman  today.  I  do  not  know  whether  she  is  cured  or  not,  and  I 
told  her  that  we  would  have  to  wait  until  next  spring  and  see  what  is 
going  to  happen,  and  that  I  could  not  tell  at  present  whether  she 
would  be  a  well  woman  or  not. 

Now,  gentlemen,  I  am  going  away  from  this  conference  before 
you  change  my  opinion  again  that  the  product  of  corn  is  not  the 
cause  of  pellagra.  I  do  not  believe  it  is  communicable.  I  do  not 
believe  that  it  is  contagious ;  therefore,  I  am  not  afraid  of  it  in  these 
two  channels. 


76 


SOME  DIFFERENTIAL  POINTS  IN  THE  SKIN  LESIONS 

OF     PELLAGRA— REPORT     OF     A     CASE     WITH 

REMOVAL  OF  SYMPTOMS 

ISADORE  DYER,   PH.   B.,    M.   D. 

Professor    on    Diseases    of    the    Skin,    Medical    Department,    Tulane    University    of 

Louisiana. 

NEW    OBLEANSj    LA. 

There  should  be  some  clear  definition  of  the  symptomatology  of  the 
cutaneous  evidences  of  pellagra  so  that  the  diagnosis  may  be  made 
by  any  observant  physician.  At  present  the  varied  reports  of  cases, 
many  incomplete,  lead  to  confusion  in  diagnosis,  and  perhaps  may 
mislead  to  the  report  of  cases  as  pellagra  which  are  something  else. 

When  Dr.  Searcy  was  studying  his  pellagra  cases  at  Mt.  Vernon 
Asylum  in  Alabama  he  came  to  New  Orleans  and  showed  me  photo- 
graphs and  specimens  which  I  could  not  recognize  as  fulfilling  the 
essentials  for  a  diagnosis  of  classic  pellagra.  The  mass  of  his  cases 
have,  however,  since  then  established  the  correctness  and  value  of  his 
observations. 

Since  the  agitation  of  the  pellagra  question  in  the  South  I  have 
seen  several  cases  which  might  have  been  mistaken  for  pellagra,  and 
most  of  these  went  on  to  fatal  terminations. 

Altogether,  I  have  had  the  opportunity  of  observation  in  four 
cases  of  pellagra,  two  in  my  own  practice.  I  have  had  two  other 
cases  of  undoubted  pellagra  under  my  advice — one  in  Mississippi  and 
one  in  Louisiana.  In  no  two  of  these  six  cases  were  the  skin  evi- 
dences just  alike,  yet  all  were  cases  of  comparatively  recent  develop- 
ment, and  all  in  their  first  attack. 

The  cases  seen  by  me  had  certain  points  in  common,  but  v/ere 
sufficiently  dissimilar  to  suggest  the  probability  that  the  skin  evi- 
dences of  pellagra  are  more  apt  to  be  the  direct  reflections  of  the 
associated  etiologic  factors  than  a  separate,  integral  symptom,  and 
that  the  severity  and  the  type  of  the  lesions  are  significantly  propor- 
tionate to  general  systemic  involvement.  I  have  some  photographs 
sent  me  by  Dr.  J.  D.  Donald,  of  Hattiesburg,  Miss.,  taken  of  the 
hand  of  a  case  of  undoubted  pellagra.  His  case  died*  after  an  attack 
of  a  few  weeks'  duration,  but  developing  fulminating  eruptions  and 
disturbances  of  all  membranes,  especially  mucous  membranes  of 
mouth,  genitals  and  adjacent  organs.    The  photographs  are  excellent 


•Report  of  Dr.   Donald's  case  related   In  Case  II. 


77 

delineations  of  pellagra — when  you  know  that  they  were  taken  of  a 
pellagrin's  hand.  They  would  as  readily  be  taken  for  photographs  of 
a  case  of  blastomycosis,  the  papillary  character  of  most  of  the  erup- 
tion being  quite  apparent.  Yet  the  beginning  and  the  course  of  this 
eruption  on  the  hands  was  as  typical  as  it  could  be  in  a  classic  case  of 
pellagra. 

My  first  patient  (Case  HI,  infra)  with  pellagra  presented  an  en- 
tirely different  eruption.  The  hands  were  affected  on  the  dorsal  sur- 
faces, particularly  associated  with  the  orifices  of  the  hair  follicles ;  the 
joint  areas  were  softer  and  less  involved.  While  the  entire  dorsal 
surfaces  of  the  hands  were  covered,  the  areas  between  the  joints 
were  especially  thick  and  rough,  made  up  of  closely  aggregated 
papules,  pin-head  sized,  uniform,  and  so  rough  as  to  be  almost  spinous 
to  the  sense  of  touch.  This  eruption  of  the  hands  extended  in  long 
triangles  up  the  extensor  surfaces  of  the  forearms  and  the  lower 
third  of  the  arm,  the  base  of  the  triangle  being  at  the  wrists  and  the 
apex  just  above  the  olecranon  process.  At  no  point  after  leaving  the 
wrist  was  the  triangle  wider  than  two  inches,  and  the  tapering  was 
almost  geometrical  in  contour. 

The  coloring  in  the  eruption  was  peculiar — the  yellow,  tan  color 
of  bran.  A  like  eruption  was  on  the  legs,  but  here  the  worst  erup- 
tion was  just  below  the  knee,  tapering  in  a  triangular  form  to  the 
ankles,  where  it  stopped.  This  case  had  typical  "rough  skin"  with 
fine  scales  on  the  surface. 

Except  for  the  configuration,  the  absence  of  itching,  and  the  asso- 
ciated symptoms,  a  diagnosis  of  pityriasis  rubra  pilaris  would  have 
been  more  than  probable. 

When  first  seen  this  patient  had  a  severe  stomatitis,  anorexia,  diar- 
rhoea (with  frequently  bloody  stools),  the  genitalia  were  engorged, 
raw,  excoriated,  painful,  and  the  menstrual  periods  had  been  attended 
with  unusual  dearth  of  flow. 

Hebetude,  emaciation  and  insomnia  nights  were  marked  symptoms. 

My  second  patient  (Case  IV,  infra)  was  a  man  of  49  years  of  age, 
giving  the  history  of  a  laparotomy  for  appendicitis  some  six  weeks 
before  the  eruption  appeared  on  his  hands.  He  had  no  eruption  or 
other  symptom  save  that  which  was  present  on  his  hands. 

This  showed  as  a  bilateral  and  symmetrical  eruption  covering  the 
dorsal  surfaces  of  the  hands,  even  to  the  edges  of  the  finger  nails. 
The  eruption  extended  up  on  the  wrists  and  encircled  the  wrists.  The 
eruption  on  the  wrists  was  marginated  by  a  waving  band  of  infiltra- 
tion, smooth,  elevated,  dull  red  in  color,  and  at  the  border  considera- 


78 

bly  lighter  than  the  rest  of  the  affected  area  on  the  wrists.  All  of  the 
eruption  on  the  wrists  was  swollen  but  unbroken.  On  the  backs  of 
the  hands,  however,  and  on  the  fingers,  even  along  the  linear  aspects 
of  these,  there  were  many  small  vesicles,  so  superficial  as  to  break 
easily,  and  in  places  had  already  crusted.  Where  the  crusts  had  dried 
some  time,  the  areas  of  the  eruption  presented  distinct  papillomatous 
elevations  closely  packed,  rough  on  top,  scaling  and  a  deep  yellow  in 
color.    At  no  time,  so  the  patient  stated,  had  the  vesicles  been  large. 

This  case  presents  the  picture  of  a  classic  pellagrous  skin  on  the 
hands.  It  is  easily  differentiated  from  vesicular  eczema  by  the  per- 
sistence of  the  vesicles,  the  development  of  papillary  areas  and  by 
the  marginate,  erythematous,  elevated  and  infiltrated  border,  all  of 
the  latter  evidences  testifying  to  a  deep  seated  affection,  beginning 
deep  and  not  a  mere  catarrhal  process  started  in  the  mucous  layer. 

Now,  each  of  these  three  cases  present  types  of  pellagra  with 
resemblances  to  other  affections.  Each  began  with  an  erythematous 
process,  at  one  stage  having  nothing  especial  to  distinguish  it  from 
an  erythema  of  ordinary  type  and  of  simple  origin. 

As  the  group  of  erythema  multiforme  has  been  studied  its  variants 
have  increased  considerably,  including  many  diseases  of  the  skin  of 
exudative  origin  and  due  to  as  many  different  causes.  We  find  the 
erythema  of  caloric  type,  caused  by  too  much  heat,  cold,  or  sunshine 
when  too  direct,  exactly  similar  erythemas  starting  from  the  inges- 
tion of  certain  drugs,  or  even  certain  foods. 

Reflex  conditions  in  the  habit  of  the  individual  may  bring  on  sim- 
ple or  grave  exudative  erythemas,  the  borderline  between  these  and 
destructive  neuroses  being  hard  to  define  at  times.  Toxins  from  food 
and  even  the  injection  of  serums  or  vaccines  in  susceptible  individuals 
may  profoundly  affect  the  skin,  even  causing  areas  of  hemorrhage 
and  of  destructive  sloughings,  if  the  hemorrhage  is  diffuse. 

As  the  degree  of  this  or  these  antagonistic  substances  may  affect 
the  individual,  so  the  results  may  appear,  locally  or  generally,  involv- 
ing the  skin  more  or  less  profoundly  at  the  same  time. 

This  idea  alone  can  satisfy  my  own  unrest  at  the  varieties  of  pel- 
lagra which  are  being  described.  So  many  of  Searcy's  cases  were 
bullous  in  type.  The  beautiful  illustration  which  accompanies  the 
pellagra  article  by  Rist  in  the  Pratique  Dermatologique  (Tome  3), 
pictures  a  dermatitis  of  foliaceous  form  with  vesicles  undeveloped. 
Others  frame  a  description  of  hands  which  are  keratosed  and  fis- 
sured. 

With  each  of  these  forms,  however,  there  are  related  enough  con- 


79 

comitant  symptoms  to  fix  the  diagnosis  of  pellagra.  I  believe  it  is 
wrong,  then,  to  state  that  the  erythema  is  the  characteric  symptom  of 
the  disease,  and  particularly  when,  as  in  some  instances,  the  erythema 
has  given  place  to  hyperplastic  changes  in  the  skin. 

The  symptom-complex  in  pellagra  should  be  arrived  at  by  asso- 
ciated evidences,  if  possible. 

Just  as  I  am  satisfied  that  I  might  have  to  prove  the  diagnosis  of 
any  one  of  my  cases,  just  so  I  am  certain  that  there  may  be  cases  aris- 
ing during  the  present  campaign  against  the  disease  in  which  I  might 
have  the  right  and  reason  to  question  the  diagnosis.  Most  other  dis- 
eases of  the  skin  have  more  exact  characteristics,  for  the  reason  that 
they  are  usually  more  specific  in  their  etiology  and  pathology  and  the 
variant  in  symptoms  of  local  nature  is  not  as  elastic  or  irregular  as  it 
would  appear  to  be  in  pellagra. 

I  now  wish  to  report  briefly  the  few  cases  which  have  come  under 
my  care,  either  directly  or  indirectly,  in  order  that  they  may  be  made 
of  record,  and  that  a  further  memorandum  may  be  made  of  the  treat- 
ment followed,  as  this  seems  to  differ  somewhat  from  accepted 
methods. 

Case  I. — Miss  S.,  Alabama.  First  seen  June  23,  1908.  Patient 
related  that  the  condition  had  appeared  early  in  March,  the  first 
symptom  being  a  sore  mouth,  as  she  expressed  it,  "like  salivation." 
The  eruption  on  the  hands  appeared  on  the  3d  of  May,  now  limited 
only  to  the  hands,  forearms  and  neck.  The  type  of  eruption  was  dis- 
tinctly erythematous  without  scaling,  a  dull,  brickdust  red  in  color, 
having  the  appearance  of  sunburn.  Eruption  was  bilateral  and  sym- 
metrical on  the  extensors  of  both  forearms,  the  backs  of  the  hands 
and  on  both  sides  of  the  neck.  The  patient  related  that  she  had 
grippe  in  February  and  had  not  been  well  since. 

The  following  blood  examination  was  made,  which  seems  to  bear 
very  little  on  the  case : 

Examination  of  Specimen  of  Blood  Smrear. 

4,540,000  red  blood  cells  to  cu.  m.  m. 
4,120  leucocytes  to  the  cu.  m.  m. 
No  Plasmodia  malarise  found. 

The  patient  was  not  seen  again,  but  the  physician  referring  her  to 
me  wrote  subsequently  that  she  had  entirely  recovered,  the  eruption 
having  then  disappeared  under  the  treatment  advised,  which  con- 
sisted in  regular  doses  of  quinine  sulphate  three  times  a  day,  two 
grains  at  the  dose,  and  salicylate  of  soda  at  the  same  dosage. 


8o 

Case  II. — Mrs.  X.  (Dr.  Donald's  case).  I  wish  to  quote  Dr. 
Donald's  description  of  this  case  as  given  in  his  letters  to  me  for 
the  chief  reason  that  no  alteration  of  his  narrative  of  the  case  could 
in  any  way  increase  the  value  of  his  observations  so  excellently 
given : 

"The  case  as  I  know  it  presents  the  following  history,  viz. : 
Female,  age  34,  married,  mother  of  one  child,  11  years  old.  Had 
had  laceration  of  cervix  and  pelvis;  has  had  several  operations  for 
their  repair;  has  never  been  very  well  since  the  child  was  born. 
First  seen  by  me  about  five  weeks  since  (April  i,  1909).  At  that 
time  complained  principally  of  a  rundown  feeling,  loss  of  appetite 
and  general  weakness ;  no  special  pain.  Rather  thin,  pale  and 
cachectic  look;  tongue  slick,  divested  of  epithelium  and  red.  Com- 
plained of  general  burning  in  stomach  and  bowels.  Uterus  enlarged, 
soft  and  bled  on  slight  manipulation.  Was  put  on  tonic  treatment 
but  continued  to  decline  for  three  weeks.  Burning  grew  worse 
about  this  time;  dark  red  erythematous  spots  appeared  on  back  of 
hands,  across  the  metacarpophalangeal  joints  and  spread  rapidly 
over  entire  dorsal  surface  of  hands ;  is  very  annoying,  burning  and 
painful.  Spreads  to  anterior  surface  of  wrists,  one  week  later 
begins  to  desiccate  and  desquamate.  The  latter  is  now  very  marked 
and  extensive ;  line  of  demarcation  from  sound  tissue  very  marked. 
Tongue  and  buccal  mucous  membrane  at  this  time  very  much 
inflamed  and  covered  with  small  ulcers  very  thickly.  Profuse  sali- 
vation, constant  nausea;  no  diarrhoea  but  constant  irritation  and 
burning  about  anus  and  vulva.  Temperature  within  the  last  ten  days 
varies  from  99  1-2  degrees  a.  m.  to  102  degrees  p.  m.  No  mental 
symptoms  thus  far,  but  physical  prostration  very  marked. 

"Treatment  at  first  was  Gooddell's  chlorides,  then  1-3  grain  doses 
argent  nit.  before  meals  with  lac  bismo  and  maltopepsine  after 
meals.  Now  1-8  drop  doses  of  carbolic  acid  with  i  oz.  doses  Phil- 
lip's milk  of  magnesia;  soothing  applications  to  hands;  1-150  grain 
doses  of  atropine  sulph.  for  salivation ;  all  of  which  has  done  abso- 
lutely no  good. 

"I  find  that  the  husband  suffered  from  a  similar  trouble  for  three 
years,  but  of  a  much  milder  type.  He  has  now  been  well  about  18 
months,  with  the  exception  that  his  mind  is  not  near  so  active  as 
formerly. 

"My  diagnosis  is  pellagra ;  any  light  you  may  give  me  will  be  very 


8i 

much  appreciated.    Have  had  the  hands  photographed  and  will  send 
you  a  copy  if  you  wish. 

"Trusting  to  hear  from  you  at  once,  yours  most  respectfully. 

(Signed)  "J.  D.  Donald." 

N.  B.  (I  suggested  the  administration  of  quinine  in  large  doses, 
but  the  suggestion  came  too  late  as  the  subsequent  details  will  show. 
—Dyer.) 

"April  2y,  1909. 

"I  enclose  herewith  photos  of  hands  as  per  promise ;  should 
have  preferred  to  have  had  them  colored,  but  could  not  get  it  prop- 
erly done.  My  patient  continued  to  go  to  the  bad  rapidly;  the 
desquamation  of  hands  was  complete,  extending  into  the  palms ;  the 
eruption  around  anus  and  vulva,  extensive  and  destructive,  extend- 
ing well  into  the  vagina.  Delirium  set  in  four  days  since,  rapidly 
increasing  until  this  A.  M.  at  5  :30  o'clock  when  death  closed  the 
scene. 

"Nothing  ever  seemed  to  benefit  her  in  the  least;  on  the  other 
hand,  actually  all  medicine  seemed  to  aggravate  the  disease. 

"I  trust  I  shall  not  again  meet  with  a  similar  case.  I  thank  you 
very  much  for  your  letter  and  the  interest  you  manifested  in  the 
case.  I  feel  that  I  would  not  fully  have  discharged  my  duty  to  the 
profession  nor  to  humanity  if  I  should  not  publish  the  case." 

I 
Case  III.     Mrs.  T.,  Louisiana.     First  seen  June  17,  1909.     Age 

25.     Two  months  ago  eruption  began  on  hand,  two  months  after 

child  birth.     Eruption  began  with  "chapping  of  both  hands" ;  now 

involves  both  hands,  forearms,  as  well  as  the  mucous  membranes 

of  mouth,  throat,  genitals ;  the  bladder  as  well  affected.     Nausea 

constantly  present  without  reference  to  injestion  of  food. 

Examination  of  the  patient  showed  her  to  be  emaciated, 
depressed,  apathetic  and  indifferent  "to  most  everything  about  her. 
No  specific  nervous  symptoms. 

She  was  promptly  placed  on  large  doses  of  quinine  (ten  grains 
A.  M.  and  P.  M.)  for  seven  days,  which  was  administered  in  the 
form  of  the  hydrobromate,  as  patient  expressed  a  fear  of  idiosyn- 
crasy with  the  drug.  In  addition  to  the  quinine  the  following  pre- 
scription was  given  after  meals : 

Rx.  Liquor  sodii  arsenitis,  2  drops ; 
Tinct.  nucis  vomicae,  10  drops  ; 
Elixir  lactat.  pepsin,  i  drachm. 

c— p.  c. 


82 

For  the  first  two  weeks  of  treatment  the  patient  improved  very- 
little;  strychnin  had  to  be  administered  from  time  to  time  and  her 
dietary  had  to  be  reduced  to  liquid  food.  The  eruption  on  the 
hands  and  arms,  and  that  on  the  legs  (described  in  main  text  of  this 
paper)  materially  improved,  losing  its  inflammatory  character  and 
drying  to  the  appearance  of  sand  paper  on  the  skin.  The  mucous 
membranes  of  the  mouth  and  genitals,  however,  kept  raw  and 
seemed  to  refuse  to  heal  under  any  treatment  at  first.  Daily  starch 
baths  with  permanganate  mouth  wash  and  douches  finally  proved 
effective,  and  at  the  end  of  about  three  weeks  the  general  symptoms 
improved  and  the  patient  was  convalescent. 

When  last  seen,  the  first  week  in  October,  the  patient  had  no 
evidences  of  the  disease  whatsoever;  had  grown  stout,  her  appetite 
had  returned  and  she  expressed  herself  as  feeling  free  of  any  dis- 
tressing symptom  of  any  sort.  On  October  26  a  report  from  the 
home  of  the  patient  stated  that  she  was  "still  improving;  no  new 
symptoms." 

The  treatment  with  quinine  was  maintained  throughout  in  this 
patient  and  stopped  only  on  her  visit  to  me  in  October,  and  "the 
following  prescription  ordered  to  be  taken  for  six  or  eight  weeks 
without  interruption : 

Rx.  Liqour  sodii  arsenitis,  4  drachms; 

Tinct.  nucis  vomicae,  i  oz. ; 

Tinct,  cinchonge,  6  oz. ; 

Elixir  simplicis,  q.  s.  12  oz. 
M.  et  Sig:  Teaspoonful  after  meals  in  water. 

Case  IV.  Mrs.  McK.,  Mississippi.  Age  42.  This  patient  was 
seen  by  my  associate,  Dr.  Henry  E.  Menage,  on  September  25,  1909. 
He  reported  the  case  as  typical  of  classic  pellagra  with  a  history  of 
one  and  a  half  months'  duration  for  the  eruption.  Patient,  however, 
had  shown  progressing  debility  for  four  months,  with  bad  memory. 
The  eruption  was  described  as  xerodermic  and  occurring  on  the 
hands,  forearms  and  over  the  olecranons ;  some  on  the  ears.  A 
blood  examination  was  made  by  Dr.  C.  C.  Bass,  which  is  interesting, 
as  showing  a  positive  Wasserman,  as  follows: 

Hemoglobin 46% 

Red  Cells 3.i35.ooo 

Leucocytes 8,700 

Small  mononuclears 19^ 


83 

Large  mononuclears 3% 

Polymorphonuclears 78% 

Wasserman's  reaction  positive  with  both  lecithin  and 
liver   extract   as   antigen. 

This  patient  was  treated  with  atoxyl,  but  this  was  discontinued 
and  the  quinine  and  arsenic,  nux  vomica,  &c.,  was  given  instead. 
Irregular  reports  were  received  from  the  patient,  but  stating  that 
her  condition  had  improved. 

Case  V.  Mr.  B.,  Mississippi.  First  seen  October  7,  1909.  His- 
tory of  recovery  from  laparotomy  for  appendicitis  six  weeks  ago. 
Eruption  present  not  over  three  weeks ;  began  with  redness  and 
swelling.  Not  restricted  in  dietary  since  discharged  after  operation. 
Does  not  eat  corn  products  habitually.  General  and  family  history 
good.  Married,  with  children.  General  appearance  good;  complex- 
ion clear;  no  sign  of  emaciation;  no  nervous  symptoms  whatever 
and  has  had  none.  Above  average  intelligence.  Clearly  under- 
stands the  seriousness  of  his  condition. 

The  eruption  on  both  hands  covered  the  dorsal  surfaces  of  fingers, 
body  of  hand,  and  also  whole  of  the  wrists ;  the  latter  are  encircled 
by  the  eruption  which  here  appears  as  an  infiltrated  erythema,  deep 
dull  red  in  color  with  a  yellow  tinge.  The  borders  of  the  erythema 
are  very  much  elevated  above  the  level  of  the  rest  of  the  eruption. 
No  break  in  the  skin  on  the  wrists.  On  the  hands  and  fingers  a 
marked  high  grade  inflammation  in  process.  Vesicles  plentiful  and 
close  together,  especially  broken  in  the  centre  of  the  hand  with 
weeping.  The  vesicles  over  the  fingers  seem  to  be  most  recent  and 
here  they  are  most  numerous.  The  part  of  the  hands  next  to  the 
wrist  is  covered  with  marked  keratinization  associated  with  papillary 
growths.  Some  scaling.  The  whole  area  of  the  eruption  is  char- 
acterized by  the  yellow  pigmentation  and  both  hands  are  consider- 
ably swollen.  Not  much  pain  nor  much  itching;  generally  uncom- 
fortable. 

Treatment  was  begun  at  once  with  instructions  to  the  patient  to 
take  quinine  hydrobromate  in  ten  grain  doses  twice  a  day  for  three 
days ;  then  five  grain  doses  three  times  a  day  for  three  days ;  then 
five  grains  twice  a  day  for  a  week.  In  addition,  the  patient  was 
given  a  prescription  calling  for  the  following : 

Rx.  Liquor  sodii  arsenitis,  2  1-2  drachms ; 
Tinct.  nucis  vomicae,  i  oz. ; 
Tinct.  cinchonse,  2  oz. ; 
Elixir  calisayse,  qs.  6  oz. 


84 

A  local  application  of  a  protective  ointment  was  ordered. 

Under  date  of  October  21,  the  patient  for  the  first  time  writes  that 
the  eruption  has  dried  and  except  for  the  harshness  and  thickened 
skin  and  the  yellow  color  he  would  think  that  he  was  nearly  well. 

In  addition  to  medication  this  patient  was  instructed  to  add  to  his 
ordinary  diet  the  juice  of  one  or  two  oranges,  or  of  one  or  two 
lemons  each  day.  He  was  ordered  to  eliminate  corn  products  and  to 
add  to  his  dietary  or  to  increase  the  amount  of  rice  and  lentils. 

Patient  w^as  seen  October  27  and  presented  a  good  general  appear- 
ance. The  eruption  had  entirely  dried,  leaving  keratinized  areas 
over  dorsal  surfaces  of  fingers,  backs  of  hands  and  wrists  being 
simply  reddened — but  without  any  lesions.  Quinine  continued  in 
2  grain  doses  A.  M.  and  P.  M.,  and  the  arsenic  compound  was  also 
continued. 

This  case  is  one  of  the  six  referred  to  in  which  the  treatment  has 
not  been  conducted  long  enough  to  know  what  the  result  will  be, 
but  the  improvement  under  the  quinine  was  sufficiently  rapid  to 
argue  that  it  is  a  therapeutic  agent  of  material  value  in  the  treat- 
ment of  these  cases. 

/ 
OBSERVATIONS  ON  THE  TREATMENT  OF  PELLAGRA. 

Since  the  first  patient  with  pellagra  came  under  my  care  I  have 
realized  that  the  treatment  has  been  purely  speculative  and  that 
whatever  good  results  have  been  obtained  have  only  arrived  from 
treatment  aimed  at  a  correction  of  the  status  of  the  circulating  blood 
in  the  victim  of  the  disease.  No  great  stress  has  been  laid  by  any 
one  using  arsenical  preparations  in  claiming  that  these  had  any 
reactionary  effect  on  the  nervous  system  or  that  this  was  the  object. 
More  recent  laboratory  experiments  with  derived  serums  have  all 
pointed  to  the  need  of  antagonistic  principles  in  the  blood  and  not 
through  the  nervous  system. 

My  own  limited  experience  with  the  disease  has  emphasized  the 
one  point  that  so  long  as  the  originating  cause  of  pellagra  is 
unknown  we  may  speculate  as  to  the  factor  producing  it,  but  the 
fact  remains  that  it  presents  many  symptoms  which  argue  a  disease 
due  to  a  toxic  substance  and  symptoms  which  are  like  those  found 
in  other  diseases  in  which  the  cause  is  known. 

For  years  I  have  treated  all  types  of  toxic  erythema  v/here  the 
specific  cause  was  not  determined  with  quinine  and  salicylic  acid 
salts.     The  success  arrived  at  made  me  give  quinine   in  the  first 


85 

case  and  I  have  continued  to  use  this  as  the  mainstay  in  each  case 
of  pellagra  that  I  have  had  to  treat,  or  for  which  I  have  advised 
treatment.  In  each  case  the  symptoms  were  promptly  controlled 
with  quinine  (given  usually  as  the  hydrobromate)  in  good  sized 
doses  and  by  keeping  up  the  quinine  continuously.  In  two  cases  the 
symptoms  have  disappeared  entirely.  In  the  last  two  cases  the  treat- 
ment has  not  been  followed  long  enough  to  establish  a  definite  report, 
but  each  case  has  improved  enough  to  make  the  prognosis  favorable. 
I  have  no  argument  to  make  for  quinine  as  I  have  used  it  with 
empyric  judgment  and  have  continued  its  use  because  the  results 
have  been  good — so  far. 


86 


PATHOLOGY  OF  PELLAGRA 

H.  F.   HARRIS,   M.  D. 
Secretary  State  Board  of  Health 

ATLANTA,     QA. 

There  are  few  if  any  diseases  characterized  by  perceptible  organic 
lesions  the  pathological  anatomy  of  which  is  so  difficult  to  arrive  at 
as  that  of  pellagra. 

This  is  to  be  accounted  for  first  and  foremost  by  the  extreme 
chronicity  of  the  disease.  At  this  point  it  may  perhaps  be  well  to 
say  that  some  of  the  earlier  American  writers  on  this  subject,  and 
those  to  whom  the  credit  is  largely  due  of  calling  attention  to  the 
wide  prevalence  of  the  malady,  generally  fell  into  the  error  of 
describing  the  characteristic  exacerbations  that  come  from  time  to 
time  in  the  course  of  this  affection  as  being  "acute  pellagra."  As 
these  reports  were  usually  made  from  asylums  there  is  little  room 
to  doubt  that  probably  most,  if  not  all,  of  the  cases  referred  to 
occurred  in  persons  already  victims  of  pellagrous  insanity.  Certain 
it  is  that  in  a  large  number  of  instances  of  the  disease  that  I  myself 
have  seen,  both  in  and  out  of  asylums,  in  not  a  single  instance  could 
there  be  any  doubt  as  to  its  chronic  nature.  Still  another  difficulty 
lies  in  the  fact  that  these  patients  rarely  die  in  the  earlier  stages  of 
the  disease.  At  such  times  the  true  character  of  the  affection  from 
which  they  are  beginning  to  suffer  is  very  seldom  diagnosticated, 
and  even  where  this  is  done  the  patient  is  taken  off  by  some  inter- 
current malady  and  the  morbid  anatomy  and  histology  of  the  two 
diseases  is  almost  necessarily  more  or  less  confounded.  Since  the 
introduction  of  modern  methods  of  histologic  examination  there  is 
not  in  the  whole  literature,  so  far  as  I  am  aware,  an  account  of  a 
thorough  post-mortem  examination  in  an  uncomplicated  case  of 
pellagra  in  the  earlier  stages.  Another  difficulty  has  been  that  the 
grosser  changes  are  found  very  inconstantly  in  most  of  the  internal 
organs,  and  are  relatively  of  little  importance — it  being  in  the  central 
nervous  system,  where  the  alterations  are  of  a  microscopical  char- 
acter, that  we  have  to  look  for  the  true  seat  of  this  affection.  As  it 
is  only  within  recent  years  that  our  methods  have  been  so  developed 
that  many  of  these  alterations  can  be  made  out,  it  follows  that  the 
descriptions  of  the  morbid  histology  given  by  the  earlier  writers  is 
of  comparatively  little  importance.    In  the  absence  of  such  methods 


87 

of  examination  one  can  well  understand  and  sympathize  with  the 
despairing  statement  of  Bertherand  who  said  "from  an  excess  of 
fatality  pellagra  has  no  causation,  no  treatment  and  no  morbid 
anatomy." 

Up  to  the  present  time  all  recorded  post-mortem  examinations 
with  thorough  studies  of  the  tissues  have  been  made  without  excep- 
tion on  old  pellagrous  subjects,  and  we  are  therefore  constrained  to 
regard  as  being  typical  of  this  affection  those  alterations  discovered 
in  the  terminal  stages  of  the  malady.  I  would  have  no  hesitation, 
however,  in  predicting  that  the  future  will  show  that  the  initial 
changes  are  in  the  central  nervous  system. 

However,  before  describing  these  alterations  attention  will  be 
given  to  certain  changes  in  the  other  viscera  that  are  of  clinical 
importance,  and  still  others  will  be  mentioned  on  account  of  their 
theoretical  interest. 

Skin — A  knowledge  of  the  skin  lesions  in  pellagra  dates  from 
Casal's  first  observations  which  began  about  the  year  1735,  although 
his  monograph  on  the  subject  was  not  published  until  1762.  In  the 
meantime  Thierry  had  gained  access  to  Casal's  manuscripts,  and 
published,  in  January,  1755,  an  account  of  the  writings  of  the  latter 
on  this  subject.  The  alteration  begins,  as  first  shown  by  Reymond 
in  1889,  with  considerable  suddenness,  developing  during  the  course 
of  24  hours  after  a  prodromal  period  of  greater  or  less  length.  Merck 
has  recently  asserted  that  there  is  often  a  preliminary  rash,  occurring 
as  discreet  maculae,  that  last  from  a  few  days  to  a  few  weeks.  The 
erythema  begins  on  the  back  of  the  hands,  and  at  the  bases  of  the 
fingers.  It  is  at  first  a  livid  red,  and  after  a  few  days  becomes 
covered  with  scales  and  shed-off  epithelium ;  this  hyperkeratosis 
continues  throughout  the  course  of  the  eruption,  and  is  exceedingly 
characteristic.  The  tissues  are  swollen  as  a  consequence  of  the 
increase  of  both  blood  and  serum  in  the  derma,  and  as  a  result  the 
normal  elevations  and  depressions  of  the  skin  become  more  marked 
than  usual,  giving  to  the  back  of  the  hand  a  wrinkled  appearance; 
the  contrast  between  the  youthful  face  and  the  aged  characteristics 
of  the  hand  are  most  striking  in  some  subjects.  This  lesion  extends 
gradually  until  in  most  cases  it  covers  the  entire  backs  of  the  hands 
and  may  reach  up  to  a  greater  or  less  height  along  the  forearm 
and  even  to  the  shoulders.  It  does  not  often  extend  to  the  tips 
of  the  fingers,  but  may  do  so.  After  several  recurrences  the  backs 
of  the  hands  become  pigmented  and  in  some  cases  the  skin  becomes 
permanently  thinned. 


88 

Similar  lesions  are  observed  on  the  backs  of  the  feet,  though  by- 
no  means  so  common  as  in  the  location  already  described;  they 
always  occur  with  or  following-  the  eruption  on  the  hands.  In  that 
most  excellent  monograph  of  Valdes  that  writer  refers  to  the  fre- 
quency of  the  occurrence  of  the  lesions  on  the  backs  of  the  feet  in 
Yucatan,  and  it  would  appear  to  me  from  the  descriptions  I  have 
read  of  the  disease  as  it  occurs  there  that  it  is  more  frequent  here 
than  in  Europe.    The  erythema  may  spread  to  the  ankles  and  legs. 

In  quite  a  number  of  cases  the  lesion  is  observed  on  the  face, 
beginning  usually  on  the  bridge  of  the  nose  and  gradually  extending 
over  its  entire  surface  and  down  on  the  cheeks,  and  in  extreme 
instances  may  reach  to  the  chin  and  lips,  and  spread  itself  finally- 
over  the  entire  countenance.  It  is  more  frequent  in  men  than  women. 
The  scalp  remains  normal.  The  eruption  may  be  in  small  distinct 
spots,  though  it  is  usually  confluent.  In  some  cases  it  occurs  also 
on  the  neck  and  extends  down  the  sternum,  giving  rise  to  the  so- 
called  "Casal's  necktie." 

More  rarely  still  other  parts  of  the  body  may  be  affected,  the 
change  being  observed  on  the  elbows,  on  the  arm  and  on  the  skin, 
covering  the  popliteal  space,  on  the  scrotum,  around  the  anus  and 
in  the  perineal  region.  In  women  the  vagina  may  be  inflamed  and 
later  ulcerated.  In  a  rapidly  fatal  case  in  a  white  man,  following 
the  eruption  on  the  hands,  I  recently  observed  spots  scattered  over 
the  various  parts  of  the  body  of  an  irregular  form,  sharply  circum- 
scribed, and  pigmented  to  such  a  degree  that  they  appeared  almost 
black ;  they  were  not  preceded  by  an  erythema.  Similar  discolora- 
tions  occurred  in  the  perineal  region,  on  the  scrotum  and  around 
the  anus.  In  the  severer  forms,  particularly  the  backs  of  the  hands, 
sometimes  exhibit  small  bladder-like  elevations  filled  with  serum, 
which  later  burst,  leaving  superficial  ulcers  that  heal  very  slowly; 
occasionally  similar  lesions  are  found  on  the  backs  of  the  feet  and 
even  on  other  parts  of  the  body.  It  is  said  that  in  rare  instances 
the  erythema  may  cover  the  entire  body.  In  the  mildest  forms  of 
the  disease  no  skin  lesions  occur. 

On  microscopic  examination,  as  first  shown  by  Babes  and  Sion, 
sections  of  the  hyperemic  skin  exhibit  a  slight  serous  exudate,  with 
a  few  leucocytes,  and  peculiar  homogeneous,  metachromatic  masses 
of  what  appears  to  be  coagulated  albumin ;  the  sweat  glands  contain 
metachromatic  granulations.  The  small  nerves  show  practically  no 
change. 

In  the  stasre  of  desquamation  the  changes  are  much  more  pro- 


89 

noiinced.  There  is  hyperkeratosis  with  shedding  off  of  the  corneous 
layer  of  the  epiderma;  the  inner  epitheHum  layers  contain  much 
yellow  pigment.  The  papillae  contain  numerous  lymphocytes  and 
plasma-cells,  with  quite  a  remarkable  absence  of  mast-cells  in  all 
cases  that  I  myself  have  examined.  The  sweat  glands  are  hyper- 
trophied,  and  the  sebaceous  glands  are  dilated  and  often  contain 
bacteria.  The  skin  is  thickened  as  a  result  of  the  increased  blood 
supply,  and  from  the  presence  of  swollen,  degenerated,  elastic  fibers 
and  the  peculiar  hyalin  albuminous  substance  already  referred  to. 

Where  ulceration  occurs  there  is  complete  absence  of  the  epi- 
thelium layer,  with  more  or  less  loss  of  substance  on  the  surface 
of  the  derma.  The  elastic  and  connective  tissues  that  form  the  bulk 
of  the  latter  structure  undergo  degenerative  changes  on  the  surface, 
and  there  are  found  in  the  diseased  structures  polymorphonuclear 
leucocytes,  a  considerable  serous  exudate,  and  numerous  bacteria. 
Somewhat  lower  down  plasma  and  lymphoid  cells  are  , quite 
numerous. 

Tongue — The  tongue  undergoes  marked  changes  in  pellagra.  In 
the  earlier  stages  the  epithelium  shows  much  the  same  alteration  that 
is  observed  in  the  epiderm  in  the  affected  areas  on  the  skin.  At  a 
later  time  the  epithelial  cells  shed  off  around  the  edges  of  the  tongue, 
and  this  may  progress  until  the  entire  structure  appears  bare,  but 
a  thin  epithelium  layer  may  be  still  demonstrated  by  means  of  the 
microscope.  Numerous  deep  furrows  often  appear  on  the  back  of 
the  tongue  as  the  disease  progresses,  and  its  tissues  become  red. 
Ulceration  is  then  apt  to  occur, — first  around  the  edges  of  the 
tongue,  and  in  some  cases  at  a  later  time  on  any  part  of  its  surface. 
Microscopically  these  changes  are  practically  similar  to  those 
occurring  in  the  skin. 

Cheeks  and  Gums — Similar  alterations  are  found  on  the  gums  and 
on  the  buccal  mucous  membrane,  and  at  certain  stages,  in  many 
cases  in  the  pharynx.  As  the  disease  progresses  the  back  of  the 
pharynx  assumes  a  deep  red  color,  sharply  circumscribed  and  sym- 
metrical, this  discoloration  may  be  seen  advancing  forward  over  the 
surface  of  the  soft  palate  in  some  instances. 

Stomach — The  mucosa  of  the  stomach  is  often  found  pale,  and 
its  walls  dilated  as  a  consequence  of  atrophy  of  its  muscular  coat; 
in  some  cases  its  surface  is  quite  red  in  the  pyloric  region. 

Intestines — Similar  alterations  are  found  in  the  intestines. 
Anemia  or  hyperemia  are  particularly  frequent  in  the  jejunum, 
and  ulcers  are  apt  to  occur  in  this  situation,  and  even  more  often  in 


90 

the  ileum.  Similar  lesions  are  occasionally  found  in  the  large  intes- 
tine. Not  uncommonly  the  walls  of  the  gut  are  thinned.  The  alter- 
ation last  mentioned  is  of  some  historic  interest,  as  the  Italian  Labus 
claimed  in  1846  that  it  was  characteristic,  and  it  was  only  after  this 
view  had  been  contradicted  by  Morelli,  and  later  by  a  commission 
appointed  by  the  Congress  of  Geneva,  in  1847,  that  it  was  finally 
established  that  this  lesion  is  inconstant,  and  by  no  means  the 
anatomical  criterion  of  pellagra  as  had  been  claimed. 

Mesenteric  Glands — These  structures  have  been  occasionally 
found  hypertrophied. 

Spleen — The  spleen  is  usually  diminished,  occasionally  hypertro- 
phied.   Metastic  foci  are  sometimes  found  in  this  organ. 

Pancreas — Occasionally  this  organ  has  been  found  atrophied. 

Liver — The  liver  is  usually  atrophied,  though  it  is  sometimes 
increased  in  size.  In  five  of  my  post-mortems  the  organ  weighed 
only  once  as  much  as  loio  grams.  Cirrhosis  is  now  and  then  found. 
Microscopically  the  cells  of  the  peripheral  portion  of  lobules  are 
frequently  quite  fatty,  though  this  alteration  is  so  frequently 
observed  under  other  circumstances  that  it  scarcely  has  any  signifi- 
cance. The  central  vein  of  the  lobule  has  been  oftentimes  found 
dilated. 

Kidneys — The  kidneys  are  usually  decreased  in  size,  but  are  fre- 
quently found  to  be  normal.  Cysts  in  the  cortical  portions  are 
frequent  as  a  consequence  of  the  scar  formation  in  these  viscera. 
Microscopically  they  often  show  the  characteristic  changes  of  inter- 
stitial nephritis,  with  which  all  are  familiar,  and  which  therefore  it 
is  unnecessary  to  detail  here.  In  some  instances  the  only  alteration 
has  been  found  to  be  fatty  changes  in  the  epithelial  lining  of  the 
tubules. 

Adrenals — The  adrenals  are  normal. 

Lungs — It  is  rather  curious  that  tuberculosis  is  rarely  found  in 
the  lungs  of  the  pellagrous,  but  hyperemia,  cedemia  and  emphysema 
are  occasionally  encountered,  and  pleurisy  with  effusion  is  not 
unknown ;  all  of  these  changes  are  evidently  in  the  nature  of  com- 
plications. 

Heart — The  heart  is  often  slightly  atrophied,  and  has  been  found 
fatty  and  the  fibers  pigmented  in  some  cases ;  this  is  evidently  sec- 
ondary, and  of  no  significance.    The  pericardium  is  usually  normal. 

Oseous  System — The  bones  are  often  friable. 

Musculature — The  muscles  are.  usually  atrophied,  but  are  some- 
times normal. 


91 

Brain — Writers,  such  as  Strambio,  Fanzago,  Leghano,  VergR, 
Labus,  ^lardi,  Carraro,  Fantometti,  Rizzi,  Gorno,  Girelli,  Biscia, 
Frank,  Bayle,  Lallemand,  Aleckel,  particularly  Roussel,  and  others, 
seem  without  exception  to  have  found  nothing  further  wrong  with 
the  brain  than  more  or  less  cedema  of  the  pia-arachnoid,  along  with 
thickening,  or  thinning,  or  adhesions  in  some  cases.  In  113  post- 
mortems Lombroso  found,  in  addition  to  the  change  first  mentioned, 
atrophy  of  the  brain  in  11  cases  with  occasional  hardening  of  its 
tissues;  in  18  out  of  28  cases  the  brain  weighed  less  than  normal, 
but,  on  the  other  hand,  was  increased  in  this  particular  in  7  instances. 

By  far  the  most  interesting  communication  that  had  up  to  that 
time  been  made  on  the  changes  in  the  brain  was  an  article  by  Babes 
and  Sion  in  1899.  They  showed  the  presence  in  the  nerA'e  cells,  par- 
ticularly in  the  large  chromophilic  cells  in  the  cortex,  the  presence 
of  unmistakable  degenerative  changes.  The  tigroid  bodies  lose  their 
power  of  staining  with  basic  dyes,  and  the  cell  becomes  swollen  and 
vacuolated.  The  nuclei  are  frequently  pushed  to  one  side  and 
lose  their  power  of  taking  basic  stains,  and  present  swollen  nucleoli ; 
the  pigment  in  these  cells  is  also  dislocated,  and  instead  of  being 
around  the  nucleus  lies  scattered  throughout  the  cell-body.  The 
processes  of  the  cells  often  appear  to  be  broken  off,  and  seem 
swollen.  The  pericellular  lymph-spaces  are  dilated,  and  the  walls 
of  these  cavities  are  frequently  lined  by  yellow  pigment.  In  the 
brain  tissue  small  collections  of  lymphoid  cells  are  frequently 
encountered,  and  the  neuroglia  cells  in  the  vicinity  of  the  blood  ves- 
sels are  swollen.  These  alterations  have  been  in  the  main  confirmed 
by  ]\Iarinesco,  Rossi,  Richette  and  Grimaldi,  and  by  myself  in  this 
country,  and  are  of  great  interest  and  importance.  In  addition  to 
the  changes  mentioned,  I  would  remark  that  in  all  of  my  cases  the 
small  vessels  of  the  brain  seemed  unusually  filled  with  blood,  and  the 
privascular  lymph  spaces  are  quite  uniformly  dilated.  There  were  no 
collections  of  lymphoid  cells  anywhere  in  the  tissues.  The  nerve 
cells  showing  degenerative  changes  usually  measured  less  than  the 
normal  ones,  and  always  contain  a  greater  or  less  amount  of  acid- 
ophilic protoplasm.  TJie  cells  suft'er  to  a  varying  degree  in  different 
parts  of  the  brain.  Perhon  and  Papinian  have  demonstrated,  as 
might  have  been  expected,  that  the  neuro  fibrils  of  the  cells  show 
degenerative  changes. 

Alterations  similar  to  those  found  in  the  cerebrum  have  been 
observed  by  me  in  the  nerve  cells  of  Purkinje.  The  cell  protoplasm 
loses  its  affinity  for  basic  stains,  and  the  nucleus  undergoes  a  sim- 


92 

ilar  change.  The  cells  contain  a  finely  granular  protoplasm  that 
takes  acid  stains,  and  in  many  of  the  cells  only  the  nucleolus  retains 
its  power  of  absorbing  basic  dyes.  The  nucleus  does  not  seem  to 
be  dislocated  in  these  cells  so  often  as  in  the  pyramidal  cells.  In  all 
of  my  cases  it  was  quite  evident  that  many  cells  of  Purkinje  had 
undergone  degeneration  and  entirely  disappeared.  In  one  instance 
this  change  was  most  striking ;  in  this  case  the  molecular  and  granule 
layers  were  in  many  places  separated  by  microscopic  spaces  that 
probably  existed  during  life,  and  probably  have  the  same  significance 
as  the  dilated  lymph  spaces.  These  cerebeller  alterations  probably 
explain  the  ataxic  forms  of  the  malady.  So  far  as  I  am  aware  no 
one  has  previously  observed  these  alterations  in  the  cerebellum. 

Spinal  Cord — Changes  in  the  nerve  cells  of  the  spinal  cord  are 
practically  in  every  way  identical  with  those  occurring  in  the  brain ; 
they  were  well  described  by  Babes  and  Sion  in  the  paper  already 
referred  to,  and  have  since  been  confirmed  by  all  who  have  studied 
the  subject.  They  show  every  stage  of  degeneration  from  slight  loss 
of  chromophilic  substance  to  practical  destruction  of  the  cell-body.  In 
1883  and  1884  Tonnini  described  degenerative  changes  in  the  lateral 
columns  of  the  cord,  and  somewhat  later,  in  1890,  Belmondo 
demonstrated  the  frequent  occurrences  of  corpora  amylacas  in  both 
the  gray  and  white  substance,  and  the  presence  of  changes  leading 
to  obliteration  of  the  central  canal.  Along  with  this  there  was 
increase  in  the  neuroglia  fibers,  and  atrophy  of  many  of  the  nerves.  ' 
In  1893  Tuczec  published  an  excellent  monograph  on  the  histology 
of  the  central  nervous  system  in  this  disease.  In  eight  necropsies  he 
found  combined  scleroses  of  the  posterior  and  postero-lateral  col- 
umns of  the  cord  six  times,  and  in  two  instances  a  similar  change  in 
the  lateral  columns  alone ;  he  confirmed  the  frequency  of  the  obliter- 
ation of  the  central  canal  described  by  Belmondo.  He  also  called 
attention  to  the  curious  fact  that  portions  of  the  gray  substance  in 
the  cord  are  frequently  found  apparently  detached  from  their  normal 
situations,  and  even  lying  as  isolated  bodies  in  the  surrounding 
white  substance ;  under  such  circumstances  the  cord  is  more  or  less 
deformed  in  appearance.  In  four  out  of  five  post-mortems  I  have 
found  similar  scleroses,  and  in  every  instance  pronounced  changes 
in  the  ganglin  cells  similar  to  those  described  by  Babes  and  Sion.  I 
have  also  in  four  out  of  five  cases  found  the  central  canal  obliterated, 
though  in  no  instance  throughout  its  entire  course;  the  changes  are 
most  pronounced  in  the  lower  cervical  and  dorsal  regions. 


93 

In  one  instance  I  have  encountered  a  typical  "meningo-myelitis 
acuta,"  such  as  described  by  Belmondo.  Although  the  post-mortem 
was  made  only  a  few  hours  after  death,  the  cord  was  very  soft  and 
on  miscroscopic  examination  was  found  to  present  alterations  of  a 
most  pronounced  kind.  The  myelin  sheathes  of  the  nerve  fibers 
showed  marked  degenerative  changes,  and  the  nerve  cells  of  the 
gray  substance  exhibited  to  a  high  degree  the  alterations  already 
described.  Corpora  amyalacea  were  specially  abundant  throughout 
both  the  gray  and  white  substances. 

Spinal  and  Sympathetic  Ganglia — The  ganglion  cells  of  these 
structures  exhibit  changes  similar  to  those  found  in  the  central 
nervous  system,  though  they  are  not  as  a  rule  so  marked. 

Eyes — From  the  results  of  the  work  of  Beitti  it  is  not  improbable 
that  circulatory  changes  are  frequent  in  the  central  nervous  system 
in  pellagra,  as  he  has  shown  that  in  quite  a  proportion  of  the  cases 
the  retina  is  aenemic,  and  in  about  the  same  percentage  the  opposite 
state  of  hyperemia  occurs. 

Peripheral  Nerves — It  has  been  claimed  by  some  that  the  altera- 
tions have  been  found  in  the  peripheral  nerves,  but  this  remains 
without  confirmation. 


94 


PELLAGRA— ITS  ETIOLOGY,  PATHOLOGY,  DIAGNOSIS 
AND  TREATMENT 

C.    W.   G.   ROHRERj    M.  D. 
Medical  Assistant  to   the   State  Board   of   Health  of  Maryland. 

Baltimore,  Md.,  October  29,  1909. 

Definition — Pellagra  is  a  specific  infectious  disease,  due  to  a  para- 
sitic fungus,  namely,  the  aspergillus  fumigatus.  Locally,  pellagra 
is  characterized  by  an  erythematous,  desquamative  inflammation  of 
the  skin ;  and,  generally,  the  disease  is  characterized  by  the  forma- 
tion of  tumor-like  masses  or  granulomata  in  various  parts  of  the 
body.  Constitutionally,  the  disease  is  complicated  by  digestive  and 
neurotic  derangement. 

The  disease  may  be  either  acute  or  chronic.  A  majority  of  the 
cases,  however,  are  of  chronic  duration. 

In  the  State  of  Maryland  but  three  cases,  two  by  Dr.  Wm.  S. 
Thayer,  of  the  Johns  Hopkins  University,  and  one  by  the  present 
writer,  have  been  reported  up  to  the  present  time. 

ClassiUcation — Pellagra  should  be  classified  along  with  tubercle, 
lupus,  syphilis,  glanders  and  farcy,  leprosy,  actinomycosis  and 
rhinoscleroma,  as  one  of  the  infective  granulomata.  The  abundant 
presence  of  tumor-like  bodies,  especially  in  the  kidneys,  lungs,  brain, 
stomach,  intestines  and  spleen,  makes  the  present  writer  feel  justified 
in  vouchsafing  this  assertion.  The  superficial  portions  of  the  lungs 
and  brain,  especially  the  walls  of  the  blood-vessels,  show  them  most 
abundantly.  These  small,  nodular  lesions,  when  examined  by  the 
microscope,  resemble  very  closely  a  tubercle  with  the  giant-cells 
removed  from  its  centre,  or  a  syphilitic  gumma  with  the  giant-cells 
eliminated  from  its  periphery. 

Occurrence  in  Animals — Recently  M.  Miiller,  in  the  Journal  of 
Comparative  Pathology  and  Therapeutics,  described  several  out- 
breaks of  an  enzootic  character  occurring  in  lower  Alsace-Lorraine, 
and  affecting  horses,  cattle  and  sheep.  The  disease,  it  is  stated,  was 
caused  by  feeding  with  musty  fodder.  The  principal  symptoms  con- 
sisted in  myopathic  paresis  or  paralysis,  and  in  the  oxen  and  sheep 
in  excessive  salivation.  The  pulse  and  respirations  were  only 
increased  in  old-standing  cases.     There  was  no  fever  and  the  sen- 


95 

sorium  did  not  appear  to  be  affected.  Occasionally  animals  recov- 
ered after  a  very  long  period  of  convalescence. 

The  so-called  cornstalk  disease,  prevalent  among  cattle  in  the 
West,  is  probably  allied  to  pellagra.  "Blind  staggers,"  and  many 
doubtful  cases  of  cerebro-spinal  meningitis  in  horses,  are  believed  by 
the  present  writer  to  be  due  to  pellagra. 

The  disease  has  been  produced  experimentally  in  dogs  and  in 
chickens. 

Etiology — The  causes  of  pellagra  are  predisposing  and  exciting. 
The  principal  predisposing  cause  is  the  eating  of  improperly  cured 
maize  or  Indian  corn.  Chronic  diarrhoeal  and  dysenteric  disorders, 
especially  of  an  ulcerative  type,  have  also  been  recently  advanced  as 
possible  predisposing  causes.  Impure  drinking  water,  it  is  alleged, 
may  bring  about  these  intestinal  lesions,  and  thus  open  up  avenues 
of  entrance  for  infection  with  pellagra. 

The  use  of  corn  products  as  a  predisposing  cause  was  well  estab- 
lished in  the  fatal  case  which  this  writer  lately  studied.  After  the 
disease  had  become  plainly  evident,  the  patient  stated  that  she  could 
no  longer  eat  corn-bread,  because  it  "went  right  through  her." 

As  no  ulcers  were  found  at  autopsy  in  either  the  stomach  or  in  the 
intestines,  this  writer  believes  their  presence  to  be  accidental  or  due 
to  other  causes. 

The  exciting  cause  of  pellagra  was  formerly  believed  to  be  a 
parasitic  fungus,  sporisormin  maidis,  which  produced  a  diseased 
condition  of  Indian  corn.  Today  it  is  pretty  generally  conceded 
that  pellagra  is  caused  by  the  aspergillus  fumigatus.  Some  of  the 
fall  cases  may  be  due  to  the  aspergillus  flavescens. 

Several  observers  have  found  bacteria  in  the  circulating  blood  of 
pellagrous  patients,  and  ascribed  to  them  a  possible  etiological  sig- 
nificance. During  life  no  bacteria  were  found  in  the  circulating 
blood  of  the  one  fatal  case  recently  studied  by  the  present  writer. 
After  death  numerous  bacterial  emboli  were  found  in  the  various 
viscera  and  organs,  notably  in  the  liver  and  in  the  lungs.  These 
bacteria  were  looked  upon  as  secondary  invaders,  and  not  as  causa- 
tive factors. 

According  to  observations  made  by  the  present  writer,  the  asper- 
gillus fumigatus  grows  not  only  upon  corn,  but  also  upon  peas, 
beans,  and  other  podded  or  leguminous  plants.  It  also  grows  upon 
buckwheat  beaten  to  the  ground  by  heavy  rainstorms. 

During  a  wet  season  leguminous  plants,  such  as  peas  and  beans, 
are  liable  to  rest  upon  the  damp  ground  and  thus  form  a  nidus  or 


96 

ho|J)ed  for  the  growth  of  the  aspergillus  fumigatus.  Buckwheat 
is  sometimes  similarly  affected.  An  ear  of  com,  however,  is  the 
most  frequent  habitat  of  the  now  conspicuous  aspergillus  fumigatus. 
The  warmth  and  moisture  generated  by  an  ear  of  corn  during  an 
unusually  wet  season,  or  within  the  husk  of  an  ear  of  corn  harvested 
a  little  too  green,  furnish  ideal  conditions  for  the  propagation  and 
growth  of  the  aspergillus  fumigatus. 

Another  factor  hitherto  overlooked  in  the  causation  of  pellagra 
is  the  harvesting  of  corn  by  machinery.  The  present  writer  believes 
the  corn  harvester  has  had  much  to  do  with  the  fairly  wade  preval- 
ence of  pellagra  in  recent  years.  To  this  new  departure  in  agricul- 
tural methods  should  be  attributed  at  least  two-thirds  of  the  cases 
of  pellagra.  The  "corn  harvester,"  therefore,  can  be  classified  as  one 
of  the  "predisposing  causes"  of  pellagra. 

Corn  cut  with  a  harvester  is  usually  bound  tightly  into  small 
bundles,  and  hence  cannot  properly  dry  and  cure.  Occasionally  it 
lies  upon  the  damp  ground  several  days  before  it  is  placed  in  the 
shock.  Han-ested  while  damp  or  a  little  too  green  also  helps  engen- 
der conditions  favorable  for  the  growth  of  the  aspergillus  fumi- 
gatus. 

Corn  harvested  in  the  old  way  by  hand  is  not  bound  into  bundles, 
and  is  placed  more  loosely  in  the  shock.  The  atmospheric  air,  as 
w^ell  as  the  heat  and  light  of  the  sun,  has  free  access  to  the  ripening 
ears  of  corn,  and  as  a  rule  they  cure  properly. 

Pathology — As  has  already  been  stated,  the  present  waiter  believes 
that  pellagra  should  be  classified  with  the  infective  granulomata. 
When  examined  by  the  microscope  these  small  tumor-like  nodules 
or  granulomata  are  seen  to  be  composed  of  a  necrotic  centre  sur- 
rounded by  spindle-shaped  cells  and  small  round  cells,  very  much 
like  a  tubercle  or  a  gumma  minus  giant-cells. 

These  granulomata  are  most  abundant  in  the  walls  of  the  super- 
ficial blood-vessels  of  the  lungs,  especially  those  of  the  upper  lobe  of 
the  right  lung.  Next  to  the  lungs  rank  the  superficial  blood-vessels 
of  the  brain,  thus  furnishing  a  pathological  basis  for  the  distressing 
mental  symptoms  apparent  in  the  last  stages  of  the  disease.  Granu- 
lomata are  also  found  in  the  stomach,  intestines,  spleen,  kidney  and 
uterus. 

Another  feature  is  the  intense  congestion  noticeable  in  practically 
all  the  tissues  and  organs.  An  extreme  degree  of  gastroptosis  and 
enteroptosis  was  also  pointed  out  at  the  autopsy.  The  liver  showed 
chronic  passive  congestion,  with  numerous  bacterial  emboli  in  its 


97 

smaller  vessels.  The  stomach  at  its  lower  fourth  is  encircled  by- 
many  varicose  veins.  Attached  to  several  of  these  veins  is  a  poly- 
poid growth.  The  kidneys  contain  several  small  cysts,  and  show  a 
condition  of  chronic  diffuse  .nephritis.  Numerous  necrotic  areas 
are  also  seen.  The  cortex  is  narrow,  measuring  but  one-eighth  of 
an  inch.  Numerous  granulomatous  masses  are  found  in  the  walls 
of  the  uterus.  There  is  a  mucopurulent  discharge  from  the  internal 
OS.  The  fundus  of  the  uterus  is  filled  with  blood  and  pus.  Hence 
it  would  seem  that  the  toxic  products  elaborated  during  the  growth 
of  the  aspergilhis  fumigatus  have  a  special  predilection  for  the 
female  uterus,  similarly  to  those  generated  by  the  fungus  causing 
ergot  of  rye,  namely,  claviceps  purpurea.  The  heart  weighed  but 
5^2  ounces,  and  its  interior  was  filled  with  white  clot.  The  pro- 
portion of  the  weight  of  the  heart  to  the  weight  of  the  body  was 
as  I  to  233,  the  patient  having  been  reduced  to  eighty  pounds  in 
weight.  The  heart  also  showed  the  condition  known  to  the  Ger- 
mans as  "drop  heart."  With  the  exception  of  slight  degeneration 
of  the  posterior  columns  of  the  cervical  portion,  the  spinal  cord 
shows  no  conspicuous  change.  The  blood-vessels  of  the  brain  con- 
tain numerous  granuloma-like  masses.  The  brain  weighed  nearly 
44  ounces.  The  skin  shows  degeneration  of  its  epidermic  layers. 
The  deeper  of  these  have  been  transformed  into  keratin;  the  super- 
ficial layers  have  become  gangrenous.  The  cutis  vera  or  true  skin 
shows  little  or  no  involvement. 

Diagnosis — The  diagnosis  of  pellagra  rests  upon  the  history  of 
the  case  and  the  characteristic  symptomatology.  The  one  fatal  case 
which  eventually  came  under  my  observation  had  suffered  many 
diagnoses  and  much  treatment,  all,  however,  of  no  avail.  The  last 
diagnosis  made  before  my  advent  into  the  case  was  "chronic 
eczema." 

A  history  of  the  use  of  corn  products  as  a  staple  article  of  diet  is 
very  suggestive.  My  fatal  case,  as  her  family  informed  me,  had 
eaten  corn-bread  every  day  of  her  life,  both  summer  and  winter. 

The  characteristic  triad  of  symptoms  are : 

1.  Gastro-intestinal. 

2.  Erythematous. 

3.  Nervous. 

The  gastro-intestinal  derangement  is  usually  the  initial  symptom 
of  pellagra.     Dyspepsia,  diarrhoea  and  stomatitis  are  the  cardinal 
symptoms  referable  to  the  alimentary  canal.     My  patient  had  com- 
plained greatly  of  her  stomach  for  three  or  four  years  prior  to  the 
7— p.  c. 


98 

appearance  of  the  skin  lesions.  She  always  drank  hot  water  before 
meals — the  conventional  "hot  water  cure  for  dyspepsia."  About 
the  same  time  she  had  to  desist  from  eating  corn-bread,  owing  to  an 
obstinate  diarrhcea  which  it  caused. 

In  my  patient  the  skin  symptoms  began  with  unfailing  regularity 
toward  the  last  of  April.  The  skin  lesions  were  first  apparent  in 
April,  1907.  They  began  as  "small,  broad,  scattered  bumps."  The 
patient  and  family  thought  it  was  poison  oak.  One  of  the  neighbors 
also  diagnosed  it  as  such  and  prescribed  a  soda  water  wash;  later, 
she  prescribed  local  applications  of  hog's  lard.  The  skin  lesions 
first  appeared  on  the  dorsal  surfaces  of  both  wrists.  About  a  week 
afterwards  these  areas  "turned  red  as  flannel."  From  the  wrists  the 
erythema  extended  to  the  backs  of  the  hands  and  fingers.  About  two 
weeks  after  the  disease  had  become  apparent  upon  the  wrists  the 
feet  were  affected.  The  dorsal  surfaces  of  both  feet  were  first 
attacked,  and  then  the  ankles.  Red  spots  also  appeared  upon  both 
knees.  Several  days  before  the  feet  became  affected,  the  classical  red 
band  appeared  upon  the  forehead.  The  erythema,  characterized  by 
its  fiery  redness,  always  appeared  toward  the  end  of  April,  and  lasted 
from  three  to  four  weeks.  At  the  expiration  of  that  time  it  disap- 
peared entirely. 

The  second  attack,  occurring  in  April,  1908,  was  more  severe 
and  prolonged.  The  erythema  again  entirely  disappeared  in  about 
four  or  five  weeks.  In  April  of  the  present  year  (1909)  the  disease 
recurred  for  a  third  time.  This  third  and  last  attack  was  more 
severe  than  either  of  the  others.  The  erythema  faded  slightly,  but 
symmetrical  gangrene  of  both  feet  resulted.  She  grew  gradually 
worse  and  died  August  20th,  1909.  The  nervous  symptoms  were 
not  markedly  manifest  until  a  few  weeks  prior  to  my  patient's  death. 
She  was  delirious  at  times,  and  always  thought  somebody  was  going 
to  kill  her.  My  patient  did  not  have  any  convulsions,  but  at  times 
was  in  a  stupor.  My  patient  suffered  but  little  pain.  The  skin  from 
the  diseased  areas  could  be  cut  or  torn  without  entailing  any  suffer- 
ing. She  was  very  sensitive,  however,  to  heat  and  cold.  For  about 
a  year  and  a  half,  so  the  members  of  her  family  stated,  she  was 
getting  thin  in  flesh,  hollow-eyed,  and  of  a  swarthy  complexion. 

Treatment — The  treatment  of  pellagra,  like  that  of  other  infec- 
tious diseases,  may  be  either  prophylactic  or  curative.  Prophylaxis, 
however,  is  the  more  important.  Right  here,  and  in  the  following 
words,  I  wish  to  sound  the  keynote  of  this  Conference,  upon  proper 
prophylactic  measures  depends  the  suppression  of  pellagra. 


99 

The  essential  prophylactic  step  can  be  summed  up  in  the  one  terse 
sentence — discontinue  the  use  of  spoiled  maize  or  Indian  corn.  It 
were  better  perhaps  to  institute  measures  to  prevent  corn  from 
becoming  musty  or  spoiled.  The  proper  curing  of  corn  is  a  sine 
qua  non  in  the  prevention  of  pellagra.  This  can  scarcely  be  hoped 
where  corn  is  cut  by  machinery.  Leguminous  plants  and  buckwheat, 
which  have  lain  upon  the  damp  ground,  should  not  be  used  for 
human  food. 

The  curative  or  medical  treatment  of  pellagra  is  notoriously  unsat- 
isfactory. In  brief,  it  is  a  feeble  attempt  to  combat  the  symptoms  as 
they  arise.  The  question  of  diet  is  all-important.  Avoidance  of  the 
suspected  cereal  and  the  substitution  of  other  good,  easily  assimilable 
articles  of  food  is  the  one  thing  needful.  Among  drugs  ferruginous 
tonics  and  arsenical  preparations  are  indicated.  The  stock  diarrhoeal 
mixtures  are  advocated  for  the  gastro-intestinal  irritation.  Opiates 
may  be  called  for,  if  the  tenesmus  be  great. 

My  patient  received  one-half  ounce  of  whiskey  and  one-fortieth 
of  a  grain  of  strychnia  sulphate  every  four  hours.  Her  appetite  was 
poor,  and  about  the  only  thing  she  relished  was  ice  cream.  Five- 
minim  doses  of  atoxyl  were  given  hypodermically  every  four  hours, 
but  without  any  appreciable  results. 

Dr.  Wm.  S.  Thayer,  of  the  Johns  Hopkins  University,  apparently 
cured  one  of  his  cases  of  pellagra  by  the  use  of  thyroid  extract.  He 
gave  three  2-grain  doses  of  desiccated  thyroids  a  day  for  several 
weeks,  and  then  decreased  the  dose  to  four  or  five  grains  daily,  con- 
tinuing the  same  for  several  months. 

SUMMARY  AND  CONCLUSIONS. 

1.  But  three  cases  of  pellagra  have  been  reported  in  Maryland 
up  to  the  present  time.  Two  of  these  were  reported  by  Dr.  Thayer, 
and  the  third  by  this  writer.  Thanks  are  due  my  able  chief.  Dr. 
Marshall  Langton  Price,  Secretary  to  the  State  Board  of  Health  of 
Maryland,  for  an  opportunity  to  study  the  prevalence  of  pellagra 
in  Maryland. 

2.  Pellagra  is  an  infectious  disease,  produced  by  the  aspergillus 
fumigatus.  The  aspergillus  fumigatus  is  not  very  tenacious  of  life. 
Not  infrequently  it  is  overgrown  by  the  common  blue-green  mould 
(penicilium  crustaceum),  or  much  less  frequently  it  is  overgrown 
by  the  common  white  cottony  mold  (mucor  mucedo)  ;  hence  the 
confusion    in    regard    to   the    etiological    factor.      The    aspergillus 


lOO 

■Havescens,  to  which  the  so-called  fall  cases  of  pellagra  are  attributed, 
is  probably  a  slightly  modified  aspergillus  fumigatus. 

3.  Personally  I  believe  the  appellation  "fall  attack"  of  pellagra 
to  be  a  misnomer.  It  is  merely  a  recrudescence.  In  the  summer 
there  is  a  temporary  abatement  of  the  symptoms  due  to  the  use  of 
fresh  vegetables  and  fruits.  Upon  the  resumption  of  dry  foods  in 
the  fall  of  the  year,  there  is  a  flaring  up  of  the  spring  attack. 

4.  Pathologically,  pellagra  should  be  classified  with  the  infective 
granulomata. 

5.  The  following  is  additional  evidence  that  pellagra  is  due  to 
a  fungus :  The  skin  lesions  in  pellagra  are  similar  to  those  produced 
by  an  allied  fungus,  namely,  claviceps  purpurea,  the  organism  which 
excites  the  growth  of  ergot  of  rye. 

6.  It  was  definitely  proven  that  musty  corn  was  the  cause  of 
my  fatal  case  of  pellagra.  To  prevent  pellagra,  corn-meal  should 
be  made  from  properly  cured  corn.  Also,  avoid  eating  leguminous 
foods (  peas  and  beans),  and  buckwheat,  the  pods  of  which  have  lain 
on  the  damp  ground.  The  aspergillus  fumigatus  sometimes  grows 
upon  these  articles  of  food,  but  the  role  which  they  play  in  the  causa- 
tion of  pellagra  is  a  minor  one. 

7.  Meteorological  conditions,  especially  in  the  great  corn  belt, 
have  much  to  do  with  the  prevalence  of  pellagra.  Many  cases  are 
apt  to  follow  a  wet  season,  while  comparatively  few  will  develop 
after  a  dry  season.  A  wet  season  furnishes  ideal  conditions  for  the 
growth  of  the  aspergillus  fumigatus.  The  past  season  has  been 
a  remarkably  dry  one,  hence  we  need  not  expect  a  new  outbreak 
of  pellagra  for  some  time  to  come. 

8.  The  harvesting  of  corn  by  machinery,  that  is,  the  use  of  the 
corn  harvester,  sometimes  called  the  corn  binder,  is  responsible  for 
the  alarming  prevalence  of  pellagra  in  recent  years.  The  corn  is 
bound  into  bundles  and  cannot  ripen  or  mature  properly,  owing  to 
exclusion  of  the  air  and  sun ;  a  favorable  environment  is  thus 
afforded  for  the  growth  of  the  aspergillus  fumigatus. 


lOI 


PELLAGRA  IN  YUCATAN 

GEO.   F.  GAUMER,   M.   D. 

IZAMALj     YUCATAN,     MEXICO. 

Pellagra  is  a  non-contagious,  tropho-neurosquamous  erythema, 
due  to  a  specific  cause. 

History — Although  isolated  cases  of  this  disease  may  have 
existed  in  Yucatan  at  an  earlier  date,  yet  it  was  not  until  1884  that 
it  became  epidemic. 

In  1882  the  locusts  or  grasshoppers  invaded  the  State  in  such 
numbers  that  they  destroyed  every  cultivated  plant,  and  were 
especially  destructive  to  the  Indian  corn  or  maize. 

Corn  being  the  only  cereal  used  in  Yucatan  for  bread,  famine 
seemed  inevitable  until  the  merchants  began  to  import  corn  from 
the  United  States.  This  importation  of  corn  continued  until  1891, 
when  the  country  had  recovered  from  the  devastations  of  the  locusts. 
The  imported  corn  was  brought  from  New  York  in  the  bottoms  of 
vessels  as  ballast  and  from  careless  handling  and  bad  storage  it  v/as 
often  rendered  unfit  for  food.  During  the  voyage  this  corn  often 
got  damp  and  even  wet,  and  by  the  fermentation  caused  by  heat  and 
humidity  a  peculiar  kind  of  fungus  is  developed  which  has  been 
called  "Sporisorium  maidis."  The  constant  eating  of  corn  affected 
with  this  fungus  produces  a  vitiated  state  of  the  blood  which  leads 
to  the  slow  development  of  pellagra. 

Among  the  better  classes  the  disease  seldom  made  its  appearance. 
Whether  this  was  due  to  the  fact  that,  having  the  facilities,  their 
food  was  better  cooked,  or  because,  having  the  means  to  purchase 
the  little  corn  produced  in  the  State,  they  were  but  small  consumers 
of  the  imported  article,  it  was  the  middle  and  lower  classes  who, 
from  reduced  circumstances,  were  obliged  to  purchase  the  cheapest 
corn  in  the  market,  that  suffered  most  from  the  ravages  of  the 
disease. 

While  pellagra  had  been  known  for  many  generations  in  Italy, 
Germany  and  other  European  countries,  yet  it  had  probably  never 
before  made  its  appearance  as  an  epidemic  in  any  part  of  America; 
and  yet,  there  is  no  good  reason  why  sporadic  cases  might  not  have 
appeared  occasionally  wherever  corn  was  used  as  an  article  of  diet. 

From  1891  to  1901  Yucatan  produced  sufficient  com  for  home 
consumption,  and  new  cases  of  pellagra  were  no  longer  to  be  found, 


I02 

while  the  old  cases  ran  their  course  and  nearly  all  those  attacked  in 
former  years  died  from  the  effects  of  the  disease. 

From  1901  to  1907  the  corn  crops  were  almost  total  failures  and 
corn  was  again  imported  in  greater  quantities  than  ever  before. 
Most  of  the  corn  came  from  the  United  States,  Mobile  and  New 
Orleans  being  the  chief  sources  of  supply,  the  remainder  coming 
via  Vera  Cruz  from  the  interiors  of  Mexico,  or  nearly  the  same  dis- 
tance, by  water. 

Pellagra  again  became  epidemic,  but  was  not  then  confined  to  the 
middle  and  lower  classes,  as  in  the  former  invasion.  The  wealthy 
hemp  owners,  on  account  of  the  exorbitant  prices  paid  for  hemp, 
found  it  was  more  profitable  to  import  than  to  raise  corn  for  home 
consumption,  thus  compelling  even  well-to-do  people  to  consume  the 
imported  article,  as  the  home  product  was  no  longer  sufficient  for 
the  wealthy  families.  Pellagra  then  spread  alike  among  the  rich 
and  poor,  until,  by  the  close  of  1907,  about  10  per  cent,  of  the  inhabi- 
tants were  victims  of  the  disease,  and  at  the  present  writing  not  less 
than  8  per  cent,  of  the  adult  population  have  pellagra. 

Prodromes. — Lassitude,  occular  phenomena,  vertigo,  headache, 
general  weakness  and  occasional  digestive  disturbances. 

FIRST  STAGE. 

Symptoms — A  patient  upon  first  consulting  a  physician  com- 
plains of  a  sensation  of  heat  in  the  mouth,  throat  and  stomach, 
upon  the  exhalation  of  the  breath ;  taste  is  impaired,  there  is  anorexia 
and  frequently  ptyalism  with  a  broad,  flabby  tongue  irregularly 
marked  by  red  blotches,  a  peculiar  formication  in  the  extremities 
which  often  extends  very  gradually  to  the  whole  of  the  body.  About 
this  time  small,  smooth  and  very  lustrous  specks  make  their  appear- 
ance on  the  dorsal  aspect  of  the  hands  and  feet.  These  specks,  when 
first  noticed  by  the  patient,  are  no  longer  than  a  pin  head,  but  rapidly 
become  more  numerous  until  uniting  they  form  lustrous  patches 
which  are  checkered  off  in  little  squares,  and  these  are  separated 
by  fine  lines,  thus  giving  the  cutis  a  scaly  appearance,  which  is 
better  seen  by  drawing  the  skin  together  with  thumb  and  finger. 
This  often  covers  the  whole  of  the  body,  but  is  generally  confined  to 
the  extremities,  chest  and  back.  The  skin  takes  on  a  senile  appear- 
ance and  the  itching  becomes  almost  intolerable,  and  if  scratching 
be  resorted  to  for  relief  the  burning  that  follows  is  unendurable. 

About  this  time  the  strength  begins  to  fail,  and  the  patient  walks 
with  a  heaviness  and  a  peculiarity  in  his  step  that  he  does  not  under- 


I03 

stand.  He  can  no  longer  find  his  way  with  closed  eyes.  The  reflexes 
become  greatly  exaggerated  and  his  movements  are  incoordinate. 
His  sleep  is  much  disturbed  by  hallucinations  and  strange  dreams. 
During  his  waking  hours  he  examines  himself  minutely  and  with 
frequency,  and  soon  begins  to  carry  on  a  constant,  though  inaudible, 
conversation  with  himself  or  some  imaginary  companion. 

In  conversation  with  other  persons  it  soon  becomes  evident  that 
the  mind  wanders.  Before  completing  one  subject  another  is  begun. 
Meaningless  words  are  thrown  in  and  as  important  ones  left  out. 
The  patient's  description  of  his  disease  becomes  long  and  tedious, 
and  he  often  ascribes  as  a  cause  of  his  present  condition  some  insig- 
nificant disease  or  injury  that  befell  him  in  his  youth,  and  ends  up 
with  the  assurance  that  some  person  who,  knowing  of  the  circum- 
stances, has  taken  advantage  of  the  opportunity  to  bewitch  him. 

SECOND  STAGE 

As  time  goes  on  the  physical  sufferings  become  greater  and 
greater,  the  skin  wrinkles  more,  the  appetite  fails  and  this  is  due  to 
the  perversion  of  the  special  senses  of  taste  and  smell,  so  that  the 
patient  looks  upon  the  most  savory  dishes,  all  kinds  of  drinks  and 
even  his  medicines  as  filthy  substances  calculated  to  aggravate  his 
sufferings  if  not  to  kill  him.  Hunger  increases  the  mental  derange- 
ments. Strength  fails  until  the  patient  is  confined  to  his  chair  or 
bed.  The  mind  becomes  more  deranged  as  the  itching  and  burning 
continue  to  rack  his  nervous  system,  so  that  he  often  seeks  to  put 
an  end  to  his  sufferings  by  committing  suicide. 

The  bowels  at  first  were  often  constipated,  but  as  the  disease 
advances  a  diarrhoea  sets  in,  which  is  accompanied  by  a  progressive 
emaciation,  until  the  patient  is  reduced  to  a  mere  skeleton,  or,  in 
some  cases,  it  passes  into  a  dystentery,  which,  running  a  rapid 
course,  soon  terminates  fatally. 

THIRD  STAGE. 

Inasmuch  as  pellagra  is  a  disease  in  which  every  symptorn  from 
its  first  appearance  advances  progressively  to  a  fatal  termination  the 
third  stage  is  but  the  first  and  second  in  a  state  of  progression  in 
which  the  mental  and  physical  phenomena  predominate.  Fear  of 
impending  danger  often  makes  the  patient  want  to  flee  from  home 
and  friends,  and  to  take  refuge  in  the  forest,  but,  upon  finding  him- 
self devoid  of  strength  and  the  power  of  locomotion,  his   fright 


I04 

increases,  and  he  strives  to   escape  from  an  imaginary  bondage, 
Friend  are  no  longer  trusted,  but  are  treated  as  enemies. 

All  former  symptoms  are  progressively  intensified  until  the  patient 
loses  control  of  the  mind  and  complete  dementia  generally  occurs 
near  the  termination  of  the  disease. 

All  psychosis  are  of  the  melancholic  type  and  tend  to  make  the 
patient  cowardly,  rarely  becoming  aggressive. 

Weeks,  months  and  sometimes  years  are  spent  in  this  stage,  during 
which  time  the  patient  gradually  grows  weaker  until  he  is  unable 
to  swallow  food  or  drink,  to  utter  an  audible  word  or  to  voluntarily 
move  a  single  muscle;  thus  the  spark  of  life  is  slowly  but  surely 
extinguished. 

FORMS  OF  PELLAGRA. 

In  a  practice  of  twenty-five  years  I  have  been  in  the  habit  of 
recognizing  three  forms  of  disease  known  and  treated  here  as  pella- 
gra. These  I  have  classified  according  to  their  cause  as  pellagra, 
pseudo-pellagra  and  pelagia. 

Pellagra  is  a  disease  whose  origin  can  always  be  traced  to  the 
ingestion  of  spoiled  corn. 

Pseudo-pellagra:  A  disease  whose  origin  can  always  be  traced 
in  the  use  of  alcoholic  liquors. 

Prior  to  1900  nearly  all  of  the  liquor  consumed  in  Yucatan  was 
distilled  in  the  State,  and  came  from  sugar  cane  or  bee's  honey,  and 
up  to  that  date  pseudo-pellagra  was  quite  unknown. 

Since  1900,  for  various  reasons,  Yucatan  has  ceased  to  produce 
the  liquors  consumed  by  its  inhabitants,  and  they  are  now  concocted 
from  alcohol  distilled  from  corn  in  the  interior  of  Mexico,  and 
essential  oils  skillfully  prepared  by  experts  in  New  York. 

Since  the  artificial  drink  has  been  substituted  for  the  pure  dis- 
tillate, pseudo-pellagra  and  other  well  marked  derangements  of  the 
human  organism  have  become  quite  common. 

Pelagia:  Has  no  constitutional  symptoms  and  is  purely  a  local 
condition  due  to  exposure  to  the  direct  rays  of  the  sun  and  the 
inclemencies  of  the  weather. 

Any  two  or  all  three  of  these  conditions  may,  and  often  do,  exist 
in  a  patient  at  the  same  time. 

In  pseudo-pellagra,  as  in  pelagia,  removing  the  cause  cures  the 
disease ;  although  in  most  cases  pigmentation  remains  through  life. 

Pellagra,  in  its  primary  stages,  is  often  curable  by  the  application 
of  the  proper  remedies,  and  by  leaving  off  the  use  of  corn.  After 
mental  phenomena  have  made  their  appearance  the  disease  becomes 


I05 

incurable;  although  by  judicious  treatment  the  course  of  the  disease 
may  be  retarded  and  life  prolonged. 

In  Yucatan  pellagra  is  not  influenced  by  reasons  as  indicated  by 
Dr.  Lavinder  in  his  "Pellagra  a  Precis,"  nor  have  I  ever  been  able 
to  detect  any  increase  of  temperature  in  connection  with  the  various 
stages  of  pellagra.  Ulcers  and  ulcerative  processes  form  no  part  of 
pellagra,  but  when  they  do  occur  as  complications  they  are  very 
obstinate  and  difficult  to  cure. 

Desquamation  never  takes  place  in  the  earlier  stages  of  pellagra, 
but  in  case  of  long  standing  the  constant  scratching  causes  the 
cuticle  to  break  up  in  the  form  of  small,  w^hite,  thin  scales,  which  are 
thrown  off  in  considerable  numbers.  The  Indian  doctor  makes  his 
diagnosis  by  drawing  his  fingernail  rapidly  across  the  affected  skin. 
If  a  white  line  of  scales  is  left  in  its  wake,  the  disease  is  pellagra. 

TREATMENT. 

The  first  thing  to  be  done  is  to  put  the  system  in  the  very  best 
possible  condition  for  the  assimilation  of  food  and  for  the  elimination 
of  the  disease.  This  must  be  done  according  to  special  indications 
in  each  individual  case,  but  the  remedies  that  have  given  the  best 
results  are  rauwolfia  heterophila  in  small  doses  long  continued. 
With  the  fluid  extract  of  this  plant  many  recent  cases  can  be  cured, 
and  with  it  the  disease  can  be  very  much  retarded  in  all  cases. 

Arsenite  of  patassium  alone,  or  in  combination  with  the  rau- 
wolfia is  a  valuable  remedy  in  many  cases.  Opium  may  be  used  to 
control  the  diarrhoea,  though  it  is  liable  to  aggravate  the  nervous 
symptoms,  in  which  case  the  fluid  extract  of  coccolobamiferi,  being 
an  astringent  tonic,  is  to  be  preferred  in  all  such  cases,  and  is  much 
more  reliable. 

As  special  tonics  aristolochia  lireoipes,  salvia  serotina  and  hydras- 
tis  canadensis  are  to  be  preferred. 

The  severer  nervous  symptoms  are  controlled  by  salanun  torvum 
and  piscidia  erythrina.  Insomnia  finds  a  remedy  in  passiflora  ciliata 
and  incarnator. 

Edema  and  heart  troubles  may  be  best  controlled  by  the  use  of 
Cereus  zrandiftorus. 

The  fluid  extract  of  the  above  remedies  are  to  be  preferred. 

In  individual  cases,  and  v/hen  indicated,  good  results  may  be 
obtained  from  the  use  of  sulphide  of  calcium,  carbonate  of  lithia, 
arsenite  of  copper,  tincture  of  the  chlorid  of  iron,  acid  solution  of 


io6 


iron,  sulphate  of  strychnia,  thuja  occidentalis,  echinacse,  tagetes 
patrela,  phytolacca  mexicana  and  quinin. 

Many  other  remedies  may  be  used  to  meet  special  indications. 

As  external  remedies  few  have  any  effect,  but  the  best  results  have 
been  obtained  from  the  use  of  the  sulphide  of  soda  in  baths,  and 
ointments  of  arsenic,  carbolic  acid  or  tagetes  patula  will  often  remove 
all  external  signs  of  the  disease. 

The  hygienic  measures  to  be  employed  are  frequently  bathing 
with  water  at  a  temperature  most  agreeable  to  the  patient.  Exercise 
in  the  open  air  with  change  of  scenery  and  surroundings,  and  fre- 
quent changes  of  clothing.  Leave  off  the  use  of  corn  as  an  article 
of  diet,  and  select  a  healthful  and  nutritious  diet  of  meats,  fresh 
vegetables  and  fruits. 

DIFFERENTIAL  DIAGNOSIS. 


PELLAGRA. 

PSEUDO-PELLAGRA. 

PELAGIA. 

In   the   beginning   of  the 
disease    patient    complains 
of    a    sensation   of    heat   In 
the     mouth,      throat     and 
stomach   on   expiration. 

Normal. 

Normal. 

Sense    of    taste    Impair- 
ed ;   there  is  anorexia   and 
ptyallsm. 

Normal. 
Sometimes    present. 

Normal. 

Tongue      broad,       flabby 
and  irregularly  marked  by 
red  blotches. 

Uniformly    red.                                Normal. 

Bowels    constipated,    fol- 
lowed    by     diarrhcEa     and 
Bometimes   dysentery. 

Diarrhoea    sometimes 
present. 

Normal. 

Cuticle   assumes   a   scaly 
appearance ;      scales      lus- 
trous,    thin     and    not     de- 
tachable   until     disease    is 
far    advanced — seldom    pig- 
mented ;     only    affects    the 
cuticle. 

Dorsal   aspect   of   all   af- 
fected    Darts    become    ery- 
thematous, assumes  a  dark 
color    and    are    pigmented 
progressively  ;    scales   thick 
and     detachable — epidermis 
and    part   of   true    skin    af- 
fected. 

All  exposed  parts  be- 
come erythematous,  as- 
sume a  dark  color  and 
covered  by  large,  thick 
laminated  scales,  detach- 
able. Skin  either  oedema- 
tous  or  hypertrophied. 

Pruritus      and      burning 
deep-seated,   aggravated  by 
scratching.       Affected     dif- 
ferently by  sun  and  shade. 

Superficial,      aggravated 
by  sun's  rays. 

Slight,  but  the  burning 
is  intensely  aggravated  by 
sun's  rays. 

Muscular      weakness 
marked   and   progressive. 

The   same. 

Normal. 

I07 


PELLAGRA. 

PSEUDO-PELLAGRA. 

PBLAGIA. 

Vertigo,    occipital    head- 
ache,   insomnia,    neuralgias 
and  cramps. 

If  present  can  be  traced 
to  alcohol. 

Normal. 

Occular  phenomena  gen- 
erally present. 

If    present    alcoholic. 

Normal. 

The  gait  is  usually  par- 
alytic,     occasionally      par- 
alytic spastic  and  progres- 
sively ataxic. 

Usual    symptoms   due   to 
alcohol. 

Normal. 

Mental    phenomina    pro- 
gressive from  slightest  per- 
turbation   to    complete    de- 
mentia. 

Alcoholic   if  any. 

Normal. 

The      pellagrin       avoids 
company,  seeks  solitude,  is 
distrustful,         melancholic, 
avoids     conversation,     pre- 
fers   the    dark,    wants    no 
assistance. 

Seeks    company,     avoids 
solitude,    is     confiding,     is 
cheerful      and        talkative. 
Avoids     the     dark,     wants 
help. 

Normal. 
Indifferent. 

Epileptiform    movements 
rythmic   and   often   contin- 
ued to  death. 

Not  rythmic. 

No  movements. 

Pellagra  is  not  limited 
to  season,  age,  sex  nor 
condition  in  life. 


Limited  to  alcohol  users. 


To  persons  past  middle 
life,  who  have  been  much 
exposed  to  sun  rays. 


Attributable    to    the    use 
of  spoiled  corn. 


To  the  use  of  alcohol. 


To  exposers  to  the  sun's 
rays. 


The  pellagrin  does  not 
fear  death,  generally  un- 
conscious at  death. 


Fears  death  and  is  gen- 
erally   conscious   at   death. 


Indifferent    to    death. 


io8 


PELLAGRA  IN  JAMAICA 

D.    J.    WILLIAMS,    M.    D. 
Medical  Superintendent,   The  Asylum 

KINGSTON^     JAMAICA. 

The  existence  of  pellagra  was  recognized  in  our  wards  about  12 
years  ago,  but  as  then  it  was  unknown  in  the  West  Indies,  the  cor- 
rectness of  the  diagnosis  was  questioned,  and  the  erythematous  con- 
dition of  the  exposed  limbs  attributed  to  "sun-burn." 

The  condition  always  appearing  in  the  feeble,  listless  and  anergic 
inmates,  it  was  believed  an  error  in  diagnosis  was  made,  but  as  time 
went  on  and  similar  objective  signs  of  disease  appeared  in  cases  not 
exposed  to  the  direct  rays  of  the  sun,  we  were  forced  to  admit  the 
former  diagnosis  of  pellagra  was  correct,  and  this  has  been  confirmed 
in  more  recent  times. 

Four  or  five  years  ago,  the  disease  was  very  prevalent  in  our 
wards;  four  per  cent,  of  the  inmates — male  and  female,  in  about 
equal  numbers — were  attacked,  in  a  population  of  1,050.  With  gen- 
erous diet,  rest  in  bed  and  tonics  the  majority  improved  temporarily, 
others  made  no  improvement,  but  suffered  from  chronic  diarrhoea, 
progressive  weakness  and  emaciation  until  death  ended  the  scene. 

Owing  to  the  mental  obfuscation  of  these  inmates  it  was  impossi-- 
ble  to  obtain  a  reliable  statement  of  their  subjective  symptoms,  one 
patient  only — a  chronic  maniac — complained  of  intense  pain  in  the 
erythematous  patches  on  the  exposed  limbs  and  nape  of  the  neck. 
She  recovered  shortly  afterwards  and  hitherto  there  has  been  no 
recurrence  of  symptoms. 

With  the  object  of  ascertaining  the  truth  that  damaged  or  diseased 
maize  was  directly  responsible  for  the  disease,  I  excluded  corn-meal 
and  every  form  of  corn  from  the  inmates'  diet  for  twelve  months, 
but  as  I  found  that  cases  admitted  into  our  wards  after  the  exclusion 
of  the  corn-meal  from  the  diet  suffered  from  the  disease,  I  am  not 
prepared  to  admit  that  maize  or  Indian  corn  is  the  only  cause  of 
this  condition ;  in  fact,  I  wish  to  record  my  opinion  that  Indian  corn — 
damaged  or  otherwise — is  not  the  sole  cause  of  pellagra.  On  the 
strength  of  this  opinion  I  have  again  restored  corn-meal  as  an  article 
of  diet  here. 

Dr.  D.  M.  Sandwith,  of  London,  made  the  following  remarks  on 
last  year's  report  of  this  asylum : 


I09 

"The  severe  drought  and  shortage  of  food  stuffs  mentioned  on 
page  14  are  important  because  they  are  hkely  to  cause  an  increase 
of  pellagra,  as  has  happened  under  similar  circumstances  in  Italy, 
Egypt  and  elsewhere. 

"The  measure  mentioned  on  page  49  of  substituting  bread  for 
maize  rations  is  likely  to  be  useful  in  treating  pellagrous  patients, 
provided  maize  flour  is  not  used  in  making  the  bread. 

"Atoxyl  or  Soamin  should  be  employed  in  treating  pellagra,  as  is 
now  being  done  in  Roumania,  Egypt  and  the  Southern  United 
States,  where  the  disease  has  lately  been  discovered. 

"It  is  possible  that  some  of  the  deaths  reported  on  page  55  as 
being  due  to  chronic  enteritis  and  dysentery  are  really  caused  by 
pellagra,  which  is  by  no  means  confined  to  lunatic  asylums." 

Such,  in  a  few  words,  is  the  history  of  pellagra  in  Jamaica,  or 
rather  in  the  Jamaica  Lunatic  Asylum,  for  I  am  not  aware  the  dis- 
ease has  been  met  with  elsewhere  in  the  island. 

October  21,  1909. 


no 


PSILOSIS  PIGMENTOSA  IN  BARBADOS 

C.  G.  MANNING^  M.  R.  C.  S.  ENG.^  L.  R.  C.  P. 
Medical  Superintendent  Asylum 

BElDGBTOWNj   BABBADOS. 

We  have  had  a  disease  here  for  the  last  15  years,  or  thereabouts, 
which  the  general  run  of  medical  men  in  the  Colony  call  pellagra. 
I  do  not  know  what  has  cropped  up  in  South  Carolina,  but  I  am  sure 
that  what  we  have  here  is  not  pellagra,  and  my  reasons  for  saying 
that  are  the  following: 

L  Pellagra  is  said  to  be  caused  by  ergotized  maize  or  some  other 
disease  in  the  food  we  eat.  If  that  proposition  is  to  stand,  we  would 
naturally  conclude  that  in  an  asylum  like  the  one  I  am  in  charge  of 
(400  beds)  where  the  maize  and  other  food  is  cooked  in  the  same 
kitchen  and  served  alike  to  patients  and  attendants,  this  disease 
would  spread  alike  to  attendants  and  patients. 

Now,  as  a  matter  of  fact,  we  have  never  had  an  attendant  have 
this  disease,  and  I  will  add  we  have  never  seen  it  in  patients  of  the 
better  class,  patients,  in  short,  who  take  a  pride  in  bathing  frequently 
and  in  keeping  themselves  clean. 

II.  The  dark  discoloration  and  squamous  appearance  of  the  skin 
does  not  appear  over  face,  chest  and  back,  nor  is  it  a  true  pigmenta- 
tion in  any  sense  of  the  term. 

It  is  scurvy  crust  which  appears  in  ninety-nine  cases  out  of  a 
hundred  on  the  elbows,  knees,  ankles,  hands  and  feet,  but  specially 
on  point  of  elbows  and  knuckles ;  very  rarely  on  the  chest,  back,  etc. 

III.  It  often  appears  and  disappears  without  leaving  a  mark, 
and  reappears  again  at  varying  distances  of  time,  but  it  is  not  a  true 
pigmentation,  white  like  a  tattoo  mark,  and  never  disappears. 

The  disease  (which  we  have  in  Barbados,  which  I  have  named 
Psilosis  Pigmentosa),  has  the  following  characteristics :  It  is  essen- 
tially a  disease  of  poverty,  hunger  and  dirt.  The  patient  first  com- 
plains of  disinclination  to  take  his  food.  Soon  he  positively  refuses 
solid  food  or  highly  seasoned  food  of  any  kind.  On  examining  the 
mouth,  tongue  and  pharynx  the  cause  is  quite  apparent.  The  tongue 
will  be  found  stripped  of  its  epithelial  covering.  At  first  this  is  most 
apparent  at  the  tip  and  along  the  edges.  It  will  be  found  that 
mucous  membrane  of  the  cheeks  and  fauces  looks  red  and  irritated. 
Patients  prefer  milk  and  this  is  the  best  nourishment  for  them, 


Ill 

because  it  is  the  least  irritating  and  most  nutritious.  Very  soon 
attacks  of  diarrhoea  set  in  and  often  prove  intractible.  Scurvy 
patches  of  dark  color  will  be  found  over  the  points  of  the  elbow, 
knees  and  knuckles.  These  generally  are  the  localities  first 
attacked;  later  on  the  feet  and  hands  become  affected,  and  if  the 
patient  wears  slippers  or  shoes  the  part  of  the  foot  which  is  cov- 
ered is  never  attacked.  The  patient  rapidly  loses  flesh  and  this  is 
followed  by  intense  anaemia,  the  brain,  like  the  other  organs  of  the 
body,  is  badly  nourished  and  cerebral  anaemia  causes  the  patient  to 
become  silly  and  half-witted,  sometimes  mouthing  and  garrulous, 
and  it  is  on  account  of  these  cerebral  symptoms  that  the  patients  are 
certified  as  insane  and  dumped  down  in  our  asylum  to  save  further 
trouble  on  the  part  of  the  parochial  authorities.  Under  regular 
feeding  and  steady  treatment  these  patients  do  wonders,  the  scurvy 
patches  disappear  and  as  the  patients  become  less  anaemic  and  so 
the  cerebral  symptoms  clear  up  and  they  become  perfectly  sane  and 
rational.  They  often  go  on  quite  well  for  years,  but  there  is  a 
tendency  for  attacks  to  recur,  and  again  with  suitable  treatment  all 
the  symptoms  clear  up  and  the  patients  appear  perfectly  well  and 
will  put  on  flesh.  But  the  disease  does  not  always  pursue  this  satis- 
factory course.  If  the  patient  is  admitted  after  the  above  prelim- 
inary symptoms  have  become  chronic  and  have  not  been  treated,  the 
disease  pursues  its  headlong  course  and  defies  all  the  skill  and  atten- 
tion that  we  are  capable  of  affording.  The  diarrhoea  becomes 
intractable  and  frequent  vomiting  is  a  most  troublesome  symptom, 
sometimes  the  ejecta  from  the  stomach  contains  streaks  of  blood, 
sometimes  clots  are  thrown  up.  The  diarrhoea  is  also  blood  stained 
and  in  one  case  I  have  seen  true  melana,  dark  tarry  stools  passed 
before  the  patient's  death.  The  smell  of  the  evacuation  is  over- 
powering and  there  is  a  sickening  odor  never  to  be  forgotten.  The 
patient  goes  to  a  skeleton,  suffers  intense  pain  right  through  the 
alimentary  canal  from  the  mouth  to  the  anus,  and  dies  simply  a 
skeleton  with  the  skin  stretched  over  it. 

The  patches  on  ankles,  dorsum  of  feet,  etc.,  if  the  patient  is  white, 
soon  have  a  purple  blotched  appearance,  and,  in  the  report  which  I 
wrote  for  our  Government,  I  described  these  as  wine-stained  patches, 
because  they  presented  the  exact  appearance  of  having  been  steeped 
in  claret.  They  are  indeed  a  kind  of  purpura,  they  form  blebs,  break 
down  and  the  epithelium  strips  off,  and  this  is  why  I  call  the  disease 
psilosis,  from  bare,  "stripped,"  Gangrene  invades  the  discolored 
area,  and  the  cutis  vera  is  the  next  to  separate  and  come  away  "in 


112 

strips,"  The  muscles  follow  suit  and  even  the  tendons  hang  in 
shreds  about  the  parts  that  break  down  so  rapidly.  The  buttocks 
soon  have  discolored  areas,  over  the  trechanters,  sacrum,  etc.,  and 
after  a  deep  burrowing  gangrene  sets  in  over  the  glutei  muscles, 
horribly  offensive  sloughs  separate  bit  by  bit  and  the  patient  sinks 
exhausted,  a  miserable  and  pitiable  object,  and  death  is  indeed  a  wel- 
come visitor. 

Follow  this  body  into  the  dead  house  and  what  do  we  find? 

Not  a  particle  of  fat  in  the  localities  where  it  is  usually  found  in 
fair  quantity,  even  in  abundance,  the  knife  goes  through  the  thoracic 
walls  exactly  as  it  would  through  parchment.  The  muscular  walls 
are  atrophied  beyond  recognition. 

There  is  not  a  drop  of  blood  anywhere  to  be  seen,  the  lungs  are 
ashen  gray,  almost  white,  contain  a  little  frothy  mucus  and  there 
might  be  a  little  serous  fluid  in  the  pleura,  but  no  blood.  The  heart 
is  pale,  flabby  and  contains  a  little  straw-colored  serum  in  the  peri- 
cordial  pouch ;  the  valves  are  probably  in  fair  working  order,  the 
muscular  walls  thin  and  pale;  if  there  is  any  blood  found  in  it,  it 
appears  in  the  shape  of  a  straw-colored  gelatinous  mass,  showing 
that  death  was  slow  and  tedious. 

The  intestines  are  empty  and  all  of  the  organs  of  the  abdomen 
testify  to  the  absence  of  red  blood  cells.  The  stomach  is  studded 
over  with  light  red  petechiae  and  they  are  no  doubt  the  cause  of  the 
blood-stained  vomit  and  the  melona,  and  there  has  been  a  slow  and 
steady  depletion  going  on,  such  as  occurs  in  cases  of  anchylesto- 
mosis.  There  is  often  a  thick,  ropy  mucus  covering  the  stomach  and 
can  be  scraped  off  with  the  knife,  leaving  the  potechise  bare  and  red ; 
sometimes  these  are  stellate  in  appearance  from  the  congestion  of 
the  vessels  leading  to  these  petechiae. 

The  intestines  are  empty,  bloodless,  and  now  and  then  have  a 
bluish  appearance  on  slicing  them  open  with  a  scissors :  the  muscular 
and  mucus  coats  are  gone  and  long  strips,  sometimes  two  or  three 
inches  long,  appear  in  the  alvine  evacuation.  If  one  is  put  under  the 
tap  and  tries  to  wash  them  they  burst  here,  there  and  everywhere, 
the  erosion  of  the  walls  leave  very  little  to  maintain  their  continuity. 
The  large  intestines  often  have  the  appearance  of  a  gut  attacked  by 
dysentery.  There  are  ulcerous  patches  and  congested  areas  quite 
sufficient  to  account  for  the  bloody  appearance  of  the  stools.  The 
kidneys  are  congested  and  often  have  a  little  blood  in  the  caluces 
and  sometimes  a  drop  or  two  of  pus. 

The  spleen  is  small  and  atrophied,  the  pancreas  is  fairly  normal  in 


113 

appearance.  The  liver  senemic  and  of  a  pale  nutmeg  color  and 
appearance,  due,  no  doubt,  to  anemia. 

The  brain  is  absolutely  bloodless,  with  slight  excess  of  fluid  in  the 
ventricles  and  hollow  places. 

Treatment — When  I  first  took  charge  of  the  asylum  in  this  Colony 
I  must  confess  that  there  appeared  very  little  hope  of  doing  anything 
for  these  poor  sufferers,  but  as  I  went  on  patiently  studying  the 
progress  of  the  disease  to  its  ultimate  and  fatal  end  I  came  to  the 
conclusion  that  the  quality  of  the  food  had  nothing  whatever  to  do 
with  causing  it.  I  soon  began  strongly  to  suspect  that  it  might  be 
caused  by  insufficient  quantity,  for  all  the  cases  I  have  seen  have 
been  absolute  paupers,  poverty-stricken  and  dirty  in  the  last  degree, 
and  also  by  being  badly  cooked,  as  this  Colony  is  bare  of  forests  and 
fire  wood  is  exceedingly  scarce  all  over  the  island, 

I  am  of  the  opinion  that  it  is  due  to  a  fungus,  and  as  soon  as  I 
discovered  that  patients  began  to  be  attacked  with  this  disease  who 
had  been  in  the  asylum,  in  some  cases  for  thirty  years,  and  who  sud- 
denly contracted  this  disease,  and  died  from  it,  I  thought  that  this 
fungus  was  not  transmitted  in  the  food,  but  in  the  clothing.  It 
occurred  to  me  that  I  would  boil  foul  linen  and  clothing  used  and 
worn  by  these  cases,  and  there  has  been  a  complete  arrest  of  the 
spread  of  the  disease  to  the  old  residents  in  the  asylum,  and,  further- 
more, there  has  been  a  marked  amelioration  in  the  symptoms  of 
those  admitted  with  the  disease  since  they  have  been  frequently 
bathed  and  supplied  with  clean  and  sterilized  clothing,  and,  indeed,  so 
hopeful  am  I  in  the  disease  that  I  am  now  writing  a  second  report 
on  this  disease  for  our  Government. 

Pointing  out  the  success  of  my  efforts  in  this  direction,  I  was  first 
induced  to  try  this  method  by  observing  that  without  a  single  excep- 
tion those  cases  with  discolored  patches  on  their  feet  always  stop 
short  and  exactly  corresponding  to  the  part  of  the  foot  covered  by  a 
shoe  or  slipper. 

Internal  Treatment — I  have  found  nothing  to  compare  with  1-40 
grain  bichloride  of  mercury  three  times  a  day  and  long  continued. 
And  milk  and  nothing  else  but  milk.  When  they  begin  to  recover, 
Scott's  Emulsion  has  given  good  results,  but  it  must  be  started  with 
small  doses  and  gradually  increased  and,  of  course,  it  is  discontinued 
if  it  upsets  the  stomach. 

From  the  success  attending  my  efforts  in  our  asylum  I  am  strongly 
of  the  opinion  that  this  disease,  if  properly  handled  in  the  earlier 
stages,  will  in  course  of  time  become  a  matter  of  history. 


114 

I  trust  that  these  notes,  hurriedly  strung  together,  might  be  of 
some  service  to  you,  and  if  they  appear  in  your  transactions,  would 
it  be  asking  too  much  to  request  you  to  send  me  a  copy? 

I  should  have  been  pleased  to  have  sent  you  some  water-color 
drawings  of  these  morbid  appearances  in  this  disease,  but  I  have 
had  no  time  to  do  so  as  your  meeting  is  booked  for  the  3rd  and  4th 
of  November. 


115 


PELLAGROUS     INSANITY     AMONG     THE     ARABS     IN 

EGYPT. 

DR.   A.    MARIE 

VILLEJUIFj     PAEIS,     FEANCE. 

Pellagrous  insanity  is  becoming  almost  unknown  in  France.  It 
does  manifest  itself  there,  however,  in  the  form  of  hereditary  insan- 
ity, as  the  recent  investigation  of  Regis  has  shown.  The  asylums  of 
Pan  and  Montpellier  are  almost  the  only  ones  where  this  affection 
persists  in  the  statistical  tables.  It  is  because  maidism  (pellagra)  is 
only  possible  where  maize  is  eaten.  To  be  poisoned  by  the  ferments 
of  spoiled  corn,  it  is  necessary  for  this  cereal  to  form  part  of  the 
prevalent  dietary,  which  perhaps  with  us  only  exceptionally  and  in 
regions  remote,  isolated  and  poverty-stricken.  Such  is  not  the  case 
in  Spain,  where  maidism  persists  in  certain  regions,  and  affects  20 
per  cent,  of  the  population. 

In  Italy,  in  spite  of  the  valiant  struggle  led  by  Lombroso  all  his 
life,  the  regions  of  Bergamo,  Brescia,  Venice  and  Padua  still  num- 
ber 30  to  50  pellagrins  to  1,000  inhabitants.  Treviso,  Vicenza,  Cro- 
mona  and  Pisa  10  to  20  per  1,000.  At  Milan  I  was  able  several 
months  ago  to  examine  a  number  of  insane  patients  of  this  kind. 
They  estimated  the  total  number  of  pellagrins  in  all  Italy  at  72,000. 

In  the  Orient  maidism  rages  in  Roumania,  Servia,  Bosnia,  Mace- 
donia, Albania  and  in  Turkish  territory  as  well  as  in  Greece. 

The  admirable  labors  of  Babes  and  Marinesco  in  Roumania  upon 
the  pathology  of  the  nervous  system  from  this  intoxication  have  sup- 
plemented those  of  the  Italian  school  to  which  we  owe  the  measures 
for  social  prophylaxis  (the  law  of  July  21st,  1902,)  originating  from 
the  Anti-Pellagrous  Congress  of  Bologna,  Padua  and  Milan. 

In  Egypt  pellagra  reigns  as  in  other  Turkish  countries  where 
corn  is  largely  used.  There  one  may  say  that  almost  all  the  fella- 
heen are  in  some  degree  touched  by  the  pellagrous  poison.  At  the 
hospital  of  Kasr-et-Nil,  at  Cairo,  in  ten  years  more  than  1,000  pella- 
grins have  been  treated.  Each  year  of  this  number  of  cases  forty  are 
complicated  with  insanity,  and  are  consequently  committed  to  the 
asylum  of  Abbassia,  where  I  was  able  to  study  them. 

Outside  of  the  hospitals,  the  study  of  pellagra  in  the  country 
population  has  been  undertaken  by  Dr.  Sanwith  ( Egyptian  Congress, 
page  485).    He  thinks  that  on  a  general  average  more  than  36  per 


ii6 

cent,  of  the  Egyptian  peasantry  are  affected.  In  districts  the  least 
poverty  stricken  the  proportion  may  fall  to  15  per  cent.,  but  else- 
where it  rises  above  62  per  cent. 

In  lower  Egypt  the  average  would  be  highest  even  with  young 
women.  The  considerable  still-birth  rate  would  not  exist  but  for 
this  plague. 

In  upper  Egypt  the  greater  dryness  and  the  use  of  millet  as  food 
lessens  the  danger,  and  probably  also  the  countries  remote  from  the 
seacoast  use  less  imported  maize,  which  is  more  dangerous  because 
of  the  ship's  hold  and  defects  of  transportation. 

At  the  asylums  which  we  visited  the  statement  of  admissions  due 
to  pellagra  from  1896  to  1906  was : 

Men.  Women.  Total. 

1896 9 

1897 10 

1898 10 

1899 19 

1900 8 

1901 27 

1902 23 

1903 41 

1904 38 

1905- •  •• 54 

1906 46 

440 

The  number  of  pellagrous  insane,  as  it  appears,  is  continually 
increasing,  and  only  those,  however,  who  clearly  bear  the  physical 
stigmata  are  enumerated,  but  the  hereditary  pellagrins  do'  not  always 
present  these  s'tigmata  thus  clearly. 

The  erythema  varies  in  appearance  according  to  the  season; 
although  its  topography  remains  the  same.  From  racial  character- 
istics it  acquires  certain  relative  pigmentary  peculiarities.  It  is  thus 
that  old  cicatrices  instead  of  contracting  by  a  darker  color  as  with 
the  white  race  manifest  themselves,  on  the  contrary,  by  a  grey  tint 
clearer  in  the  men  of  color  in  consequence  of  a  sqaumous  thickening 
of  a  thick  and  dry  epidermis. 

The  climate  and  the  Arabian  costume  direct  also  certain  peculiari- 
ties to  the  localization  of  this  erythema.  It  is  thus  that  the  short  and 
wide  sleeves  make  the  (pellagrous)   glove  more  extended  and  the 


2 

II 

13 

23 

29 

39 

14 

33 

27 

35 

10 

37 

10 

33 

II 

52 

15 

53 

II 

65 

13 

59 

117 

grandoura  opened  wide  upon  the  breast  causes  the  erythema  to 
extend  from  the  neck  to  the  sternal  region. 

Upon  the  legs  the  boot  of  erythema  often  reaches  above  the  knee 
and  the  bare  foot  is  attacked  just  as  the  hand  by  the  solar  localiza- 
tion. One  may  observe  either  the  increase  of  pigmentation  at  the 
beginning  or  the  final  depigmentation  by  a  dystrophic  state  of  the 
epidermis  which  becomes  like  parchment,  dry  and  scaly.  Frequent 
scars  from  previous  ulcerations  further  alter  the  appearance  of  the 
integument  at  the  most  exposed  positions. 

The  period  of  ulceration  is  sometimes  preceded  by  a  phase  of 
desquamation  by  shreds  of  pigmented  epidermis  which  breaks  and 
forms  fissures.  In  the  negro,  especially  upon  the  face,  the  eruption 
can  assume  the  appearance  of  grains  of  millet  pigmented  and  hard 
upon  the  forehead,  the  neck,  the  cheeks  and  the  periphery  of  the 
lips. 

We  shall  not  dwell  either  upon  the  well  known  physical  stigmata 
of  the  integument  with  their  seasonal  rhythms  or  upon  the  dominat- 
ing visceral  troubles  which  accompany  them  (diverse  gastro-intes- 
tinal  disorders,  gastritis,  diarrhoea,  etc.). 

We  shall  devote  our  space  to  mental  and  nervous  peculiarities,  the 
manifestations  of  which  are  generally  consecutive  upon  the  preced- 
ing signs ;  although  they  may  precede  them  or  in  certain  cases  be 
substituted  for  them. 

The  mental  state  of  the  patients  is  generally  characterized  by  an 
initial  phase  of  irritable  weakness,  by  an  apathy  with  physical  and 
mental  depression  and  diverse  phobias,  sitophobia  is  frequent  and 
coincides  with  the  gastro-intestinal  troubles,  gastralgia,  cramps, 
nausea,  state,  alternating  constipation  and  diarrhoea. 

Mutism  joins  sitophobia,  the  patients  become  wild  and  apprehen- 
sive, isolating  themselves  and  seeking  dark  corners  (photophobia 
and  painful  cutaneous  sensitiveness  to  heat) . 

Mental  torpor  is  accompanied  by  amnesia  and  spasms,  developing 
even  vertigo  and  epileptiform  convulsions  or  their  psychic  equiv- 
alents. In  the  first  rank  of  these  latter  mention  should  be  made  of 
walking  automatism,  a  frequent  cause  of  innocent  suicides  by  pre- 
cipitation or  submersion  in  the  canals  of  the  Nile.  Self-accusation 
or  preoccupation  with  hypochondriacal  or  nosophobia  thoughts  are 
not  rarely  associated  with  vague  ideas  of  prosecution.  Stupor  is 
mixed  with  automatic  exaltation  and  diverse  flights  (fugues)  with 
or  without  dreamy  confusional  states. 

Sitophobia  can  arise  either  from  dysphagia  or  anorexia  and  apathy 
may  border  upon  catatonia.     It  may  sometimes  give  place  to  sito- 


ii8 

mania  in  a  later  stage,  for  pellagrous  insanity  frequently  assumes  the 
chronic  form  with  or  without  the  addition  of  remissions.  This  is 
understood,  for  the  patients  after  improving  relapse  into  the  same 
condition  as  when  first  attacked  as  a  result  of  eating  spoiled  corn. 
Since  the  same  causes  reproduce  the  same  effects,  relapses  are  fre- 
quent and  also  chronic  conditions.  Besides  complications  from 
other  factors  producing  psychoses  are  not  rare. 

As  an  example  for  Eg}'pt,  we  may  cite  the  association  of  the  pella- 
grous intoxication  with  that  of  hashish.  We  may  cite  the  possible 
combination  of  diverse  infections,  of  malaria  and  syphilis  in  par- 
ticular, and  the  parasitism  evidence  in  Egypt  of  ankylostomiasis 
which  we  have  found  very  wide-spread  among  the  Egyptian  insane 
as  in  the  native  population  in  general. 

For  the  aforesaid  specific  infection,  I  have  already  described 
general  paralysis  as  frequent  among  the  Arabic  Egyptians.  Does 
pellagrous  pseudo-general-paralysis  exist  among  them,  or  is  it  a 
simple  combination  of  specific  general  paralysis  upon  a  soil  prepared 
by  the  pellagrous  intoxication  ? 

This  question  is  not  new,  and  it  is  the  French  school  which  solved 
it  during  the  resounding  Academic  debates  stirred  up  by  Baillarger 
in  1847.^ 

The  examination  of  pellagrous  insane  Arabs  of  the  asylum  at 
Abbassia  shows  that  if  true  pellagra  is  almost  constant  among  them 
as  among  the  population  from  which  they  come,  there  are  along- 
side of  the  pellagrins  who  have  become  insane — the  insanity  being 
a  consequence  of  the  pellagra  and  in  direct  casual  relation  with  it. 
They  draw  from  their  pellagrous  origin  certain  typical  characters 
connected  with  physical  stigmata. 

A  certain  number  of  insane  paralytics  coincide  with  pellagra  and 
confirm  the  opinion  of  Baillarger  that  the  final  paralytic  phase  of 
pellagra  can  represent  an  identical  state  clinically  and  pathologically 
with  general  paralysis  of  the  insane.  These  cases  do  not  invalidate 
at  all  the  other  form  of  general  paralysis  from  which  they  are  dis- 
tinct, and  which  I  have  described  as  being  in  relation  to  syphilis. 
The  two  forms  can,  however,  be  combined,  that  is  to  say,  one  may 
observe  among  the  Arabs  general  paralytics  who  are  at  once  both 
syphilitic  and  pellagrous. 


^The  question  arose  upon  a  plan  of  investigation  proposed  by  Roussel  to  the 
Minister  of  Commerce, — the  investigation  to  be  made  in  Spain  into  the  causation 
and  manifestations  of  pellagra,  which  was  then  frequent  in  Southwest  France. 
Mr.  Gilbert,  a  member  of  the  Academy,  expressed  an  opinion  contrary  to  the  theory 
of  its  origin  from  Indian  corn,  supporting  his  belief  by  cases  observed  by  him  in 
Paris  at  the  Hospital  St.  Louis.  It  was  a  question  probably  of  hereditary  pellagra 
analagous  to  the  case  reported  by  Regis  in  a  patient  having  never  eaten  corn 
spoiled  or  otherwise,  but  a  daughter  and  granddaughter  of  true  and  insane  pel- 
lagrins. 


119 


PELLAGRA  IN  EGYPT 

Hospital  for  the  Insane 

ABBASSIAj   CAIEOj    EGYPT. 

The  statistics  on  enclosed  sheet  show  how  formidable  this  disease 
is  as  a  cause  of  insanity  in  this  country.  There  are,  doubtless,  many 
thousands  of  the  poorer  fellaheen  suffering  from  this  disease  in  the 
provinces.  In  the  towns  where  syphilis  and  hasheesh  are  rampant 
and  little  maize  is  used,  pellagra  is  uncommon,  but  its  place  as  a 
cause  of  insanity  is  taken  by  the  above  agents,  and  we  have  the 
hasheesh  intoxications  and  general  paralysis  in  considerable  num- 
bers. 

Pellagra  is  very  common  among  children  in  Egypt;  apparently 
this  is  not  your  experience  in  America.  I  have  seen  scores  of  chil- 
dren from  lo  to  15  dwarfed,  cachectic,  anaemic  and  displaying 
splendid  black  pellagrous  rashes,  and  usually  insane.  The  mental 
symptoms  are  modified  by  the  age,  and  the  children  are  mischievous 
and  restless,  besides  being  depressed  and  deluded.  Some  of  them 
look  like  little  mummies.  I  think  men  suffer  more  frequently  from 
pellagra  than  women  in  Egypt,  but  this  is  only  an  opinion.  1  have 
no  figures  to  back  it. 

In  this  asylum  no  maize  is  used  in  any  form.  All  flour  is  carefully 
analyzed  and  the  diet  is  kept  absolutely  free  from  maize.  Yet  pel- 
lagrous patients  resident  here  for  years  and  thus  abstaining  from 
maize  for  long  periods  again  develop  pellagrous  rashes  here  with 
acute  physical  symptoms,  sometimes  resulting  in  death. 

The  following  are  notes  of  a  few  of  such  cases,  but  scores  of 
similar  cases  are  recorded  in  our  books. 

1.  I.  S.  S.,  Case  Book  XVI,  27.  Admitted  i8th  November,  1903. 
In  June,  1907,  he  developed  a  black  charred-looking  rash  of  neck 
with  diarrhoea  and  all  the  symptoms  of  acute  typho-pellagra,  and 
died. 

2.  S.  A.  H.,  Case  Book  XVII,  233.  Admitted  14th  March,  1908. 
On  8th  May,  1909,  he  developed  a  pellagrous  rash  with  diarrhoea 
and  acute  prostration  and  died  on  15th  May,  1909.  (See  photographs 
I  and  II,  taken  on  May  8,  1909.) 

3.  M.  D.,  Case  Book  XVII,  225.  Admitted  5th  March,  1908. 
On  3d  December,  1908,  pellagrous  rash  reappeared. 

It  is  noteworthy  that  the  rash  and  the  diarrhoea  occur  simultane- 
ously.   The  rash  is  therefore  not  a  casual  symptom  produced  by  the 


I20 


exposure  of  a  pellagrous  person  to  the  sun's  rays,  but  a  sign  of  a 
general  degenerative  process  affecting  the  whole  organism. 

Nearly  all  cases  of  acute  typho-pellagra  have  a  very  black 
indurated  rash,  and  there  seems  to  be  a  correspondence  between  the 
darkness  of  the  rash  and  the  acuteness  of  the  general  symptoms. 

Nearly  every  case  of  pellagra  suffers  from  bilharzia  disease.  Very 
many  from  anchylostoma  also,  and  very  many  from  extreme  favus 
of  the  scalp.  I  have  always  considered  that  these  parasites  have 
fixed  themselves  upon  a  decaying  organism ;  but  there  is  something 
to  be  said  for  the  possibility  that  these  parasitic  diseases  account  for 
some  of  the  symptoms  of  pellagra  (anaemic,  emaciation,  etc.).  We 
should  like  to  know  whether  in  America  you  find  these  parasitic  dis- 
eases so  frequently  (or  almost  invariably)  associated  with  pellagra? 


STATISTICS. 
Egyptian  Government  Lunatic  Asylum,   September  25,   1909. 


Year. 

Annual  Admissions  of 

Cases  of  Pellagrous 

Insanity. 

Annual    Deaths    from 
Pellagra    in    Asy- 
lum. 

Male 

Female 

Total 

Male 

Female 

Total 

1901 

23 

22 
41 
38 
54 
91 
69 
71 

10 
9 
11 
15 
11 
33 
20 
17 

33 
31 
52 
53 
65 
124 
89 
88 

6 
6 
9 
3 
13 
9 
7 
6 

4 
2 

1 
3 
4 
1 
2 
2 

10 

1902 

8 

1903 

10 

1904 

6 

1905 

17 

1906 

10 

1907 

9 

1908 

8 

The  above  has  been  extracted  from  my  annual  reports.  The  great 
increase  in  the  pellagrous  admissions  in  recent  years  is  due  to  more 
careful  examination  and  search  for  pellagrous  symptoms.  No  doubt, 
nearly  as  many  pellagrous  cases  were  admitted  in  1901  as  in  1908, 
but  their  pellagrous  character  was  not  demonstrated.  Lately  every 
case  has  been  watched  and  few  escape  diagnosis  now. 

Note — The  above  figures  refer  to  cases  of  insanity  due  to  pella- 
gra, not  to  cases  showing  pellagrous  symptoms  merely.  Thus,  we 
admit  numbers  of  congenital  imbeciles,  precocious  dements,  epilep- 
tics, senile  dements,  etc.,  who  have  signs  of  pellagra,  but  the  pellagra 
seems  a  coincident  illness,  not  a  cause  of  the  insanity,  so  their  diag- 
nosis would  appear  under  other  headings. 

I  send  some  old  reports.  If  you  will  look  up  "Pellagra"  in  their 
contents  you  will  find  many  remarks  about  pellagra  in  Egypt,  which, 
of  course,  are  at  your  disposal. 


121 


PELLAGRA  IN  EGYPT 

R.    G.    WHITE,   M.   B. 
Director   Serum   Institute 

ABBASIAj    CAIEO^    EGYPT. 

The  following  preliminary  note,  with  suggestions  as  to  the  means 
best  suited  to  take  up  the  study  of  pellagra  in  Egypt,  was  submitted 
to  Mr.  Graham,  Director-General  Public  Health  Department,  Cairo, 
in  July,  1909.  It  was  not  written  for  publication,  but  was  read  at  the 
conference  through  the  courtesy  of  Mr.  Graham  and  Dr.  White,  and 
is  now  published  with  their  consent  upon  special  request. 

The  notes  are  the  result  of  some  observations  made  during  the 
early  months  of  this  year,  and  are  not  in  any  sense  intended  as  an 
official  report  upon  an  important  subject  now  being  urged  upon  the 
Egyptian  Government. 
To  the  Director-General,  Department  of  Public  Health. 

Sir :  I  have  the  honor  to  submit  to  you  a  report  of  the  investiga- 
tions so  far  carried  out  on  the  occurrence  of  pellagra  among  the 
Fellaheen. 

These  investigations  have  been  devoted: 

1.  To  a  study  of  the  cases  as  seen  at  the  Lunatic  Asylum,  Abbasia. 

2.  To  visits  to  the  villages  and  homes  of  the  patients. 

3.  To  a  minute  examination  of  well  marked  cases  in  Zagazig,  and 
(latterly)  in  Benha. 

4.  To  carrying  out  certain  experiments. 

With  regard  to  No.  i.  Dr.  Wernock  very  kindly  gave  access  to  the 
cases  and  the  books  of  the  Asylum.  He  also  rendered  valuable  assist- 
ance in  the  way  of  suggestions  and  books  of  reference. 

On  his  suggestion,  Sharkin — the  province  giving  the  greatest 
returns  of  such  cases  to  the  Asylum — was  chosen  as  the  most  suita- 
ble place  in  which  to  begin. 

At  the  Asylum,  also,  where  a  room  was  set  aside  for  the  purpose, 
some  pathological  work  has  been  done,  and  material  collected  from 
post-mortems  on  typical  cases. 

Experiments  are  being  performed  on  the  effects  of  inoculation  of 
cerebro-spinal  fluid  obtained  in  such  a  manner.  Experiments  on 
cerebro-spinal  fluid  obtained  by  Lumbar  punctum  still  remain  to  be 
performed. 

With  regard  to  No.  2,  the  methods  of  drying,  storing  and  cooking 


122 

durra  have  been  noted  in  the  different  Markaz  towns,  as  well  as  in 
several  villages  of  Sharkin ;  samples  of  bread  and  durra  were  taken 
for  further  investigation,  either  in  the  way  of  chemical  analysis  or 
for  experiments  on  animals. 

At  the  same  time  patients  were  examined  and  suitable  ones  chosen 
for  further  examination  in  the  hospital.  A  similar  procedure  is  pro- 
posed for  Ghalioub. 

With  regard  to  No.  3,  for  purposes  of  investigation,  patients  were 
brought  to  hospital  in  order  to  be  under  closer  observation.  In  all, 
sixteen  cases  have  been  so  examined — of  these,  only  two  remained. 

In  Benha  Hospital,  where  a  start  has  been  made  on  similar  lines, 
there  are  now  five  cases  under  observation. 

With  regard  to  the  Zagazig  cases,  for  various  reasons,  ten  were 
found  unsuitable  for  investigation  and  were  discharged  cured,  either 
with  or  without  treatment  other  than  hospital  diet  and  hygiene.  The 
remaining  six  had  their  diet  or  treatment  varied,  in  order  to  observe 
any  change  in  their  condition. 

One  boy  ten  years  of  age  (see  photo.)  had  no  treatment  other  than 
three  months'  residence  in  hospital — in  which  time  his  weight  in- 
creased by  four  kilos,  and  diarrhoea  practically  disappeared.  (He 
had  no  medicinal  treatment.)  His  rash  completely  disappeared, 
although  on  admission  he  was  one  of  the  most  marked  cases.  He  has 
been  discharged,  but  his  further  progress  must  be  watched.  He  has 
to  report  himself  regularly. 

Five  cases  who  had  shown  improvement  on  the  ordinary  hospital 
diet  were  at  varying  times,  for  varying  periods,  put  on  durra  bread 
instead  of  the  ordinary  wheaten  bread  of  the  hospital.  The  durra 
bread  used  was  made  from  durra  obtained  from  a  native  house,  and 
was  prepared  from  time  to  time  in  the  usual  way  by  a  native  woman. 
The  changes  under  these  conditions  were  in  some  instances  marked, 
being  of  the  nature  of  a  toxemia.  There  was  noted  return  of 
diarrhoea,  loss  of  weight,  dull  and  listless  appearance,  with  clayey 
color  of  skin.  There  was  no  return  of  the  rash,  however,  possibly 
neither  the  length  of  time  nor  the  conditions  favored  its  return.  This 
is  a  point  worthy  of  further  investigation. 

Some  cases  showed  distinct  improvement  on  soamin.  No  conclu- 
sion, however,  can  be  drawn,  as  others  showed  a  similar  improvement 
without  any  medicinal  treatment. 

It  would  be  an  interesting  further  stage  of  the  investigation  to  live 
in  one  of  the  villages  largely  affected  as  Minet-el-Gamh.     Patients 


123 

could  be  treated  there  whilst  living  in  their  homes,  so  that  the  effects 
of  hospital  diet  and  hygiene  could  thus  be  eliminated. 

One  case,  aged  25,  (  ) ,  deserves  special  attention.    This 

patient  was  for  the  first  eleven  days  of  his  stay  in  hospital  on  hos- 
pital diet,  from  which  maize  is  totally  excluded.  He  improved  in 
condition,  and- was  put  on  durra  bread  for  three  weeks;  but  his 
symptoms  became  so  marked  that  at  the  end  of  that  time  the  hospital 
diet  had  to  be  renewed.  During  the  three  weeks  of  durra  bread  he 
lost  2.3  kilos  in  weight;  he  has  now  been  two  months  on  hospital 
diet,  and  has  put  on  5.2  kilos.  During  the  period  when  he  was  having 
durra  bread,  he  fell  off  markedly  in  condition — his  skin  became  dark ; 
but  no  rash  appeared,  and  the  diarrhoea  increased.  He  also  developed 
delusions,  but  they  have  now  disappeared,  and  his  mental  and  physi- 
cal conditions  have  much  improved. 

Another  case,  age  13,  (  ),  while  still  on  durra  bread, 

continued  to  increase  in  weight;  but  his  other  conditions  were 
marked — namely,  dull  and  depressed  state,  with  toxemic  symptoms. 
After  the  durra  bread  was  stopped  he  became  much  brighter  in 
appearance,  and  his  color  began  gradually  to  improve. 

A  point  worthy  of  note,  and  one  which  markedly  complicated  the 
clinical  picture  in  the  cases  observed,  was  the  fact  that  all  the  cases, 
especially  under  observation  in  the  Zagazig  Hospital,  suffered  from 
bilhargia;  whilst  all,  with  three  exceptions,  suffered  also  from 
anchylostoma.  This  point  is  of  great  interest,  and  may  possibly  have 
some  bearing  on  the  fact  that  patients  fall  a  victim  to  the  disease 
whilst  their  brothers  and  sisters,  living  under  similar  conditions, 
escaped. 

With  regard  to  No.  4,  namely,  experiments,  miuch  remains  to  be 
done. 

On  the  hypothesis  that  decomposing  durra  has  to  do  with  the 
causation  of  pellagra,  animals  were  fed  on  such  durra,  whilst  others 
were  fed  on  healthy  durra — as  controls. 

In  the  case  of  chickens,  there  seemed  at  first  to  be  a  stunting  of 
the  growth  of  those  fed  on  the  diseased  grain;  whilst  others,  from 
the  same  nest,  thrived  on  good  grain.  However,  after  a  time  the 
former  birds  seemed  to  get  accustomed  to  the  damaged  grain,  possi- 
bly due  to  the  establishment  of  a  tolerance  for  the  toxine  (if  much 
be  present),  or  the  grain  was  less  damaged  than  formerly,  so  that  the 
birds  seemed  able  to  thrive  on  it. 

In  the  case  of  rabbits  under  similar  conditions,  two  that  were  fed 
on  damasred  maize  showed  a  distinct  difference  from  the  controls 


124 

that  were  fed  on  good  grain,  the  difference  in  weight  in  one  case 
being  80  grammes.  The  difference  in  their  coats  was  marked — in 
the  case  of  the  former  they  were  turned  and  staring,  whilst  the  latter 
were  smooth  and  normal. 

Bread  made  from  damaged  grain  is  being  analyzed  to  see,  if  possi- 
ble, if  some  extract  can  be  found  of  the  nature  of  an  alkaloid.  Also 
the  moulds  are  being  identified  so  that,  if  possible,  they  can  be  arti- 
ficially grown,  and  so  found  pure  for  purposes  of  further  experiment 
an^  investigation. 

It  is  impossible,  at  such  an  early  stage  of  an  investigation  of  this 
nature,  to  draw  any  definite  conclusions. 

Of  the  many  theories  put  forward  as  the  cause  of  pellagra,  the 
maize  one,  from  the  great  support  it  has  received,  has  been  given 
first  place.  At  the  same  time  attention  has  been  paid  to  other  theo- 
ries {e.  g.,  the  protozoan  one),  and  blood  films  have  from  time  to 
time  been  examined. 

Judging  from  the  work  so  far  done,  one  feels  only  justified  in 
saying  that  at  least  damaged  maize,  as  found  in  some  of  the  villages, 
and  presumably  used  for  food  purposes  by  the  poorer  fellaheen, 
seems  to  cause  a  condition  of  the  nature  of  a  toxemia.  Whether  this 
is  due  to  some  poison  elaborated  by  a  fungus  growth  in  the  durra 
grain  or  to  the  fungus  itself,  only  further  research  can  decide. 

Judging  from  the  experience  so  far  gained,  the  following  would 
seem  to  be  the  best  lines  upon  which  to  continue  this  research. 

1.  That  a  continued  minute  examination  be  made  of  typical  cases, 
over  a  lengthened  period  of  time,  at  the  homes  of  the  patients  as  well 
as  in  the  hospital. 

2.  That  the  different  provinces  be  visited,  both  in  Upper  and 
Lower  Egypt,  so  that  the  differences  in  prevalence  may  be  compared 
with  the  different  conditions — either  as  to  the  nature  of  the  durra 
or  its  process  of  drying,  storing  and  cooking. 

3.  That  the  attention  of  Markaz  doctors  be  drawn  to  the  subject, 
so  that  through  their  barbers  an  estimate  be  made  of  the  prevalence 
of  the  condition  in  Egypt.  This  has  already  been  done  in  the  case 
of  Sharkia — the  numbers,  however,  remain  to  be  checked. 

•     4.  That  further  blood  examinations,  also  experimental  tests  and 
chemical  analyses,  be  carried  out. 

5.  That  an  extended  study,  over  a  lengthened  period,  at  all  times 
of  the  year  be  made,  so  that  the  difference  in  incidence  and  various 
stages  of  the  condition  be  noted. 


125 

Many  difficulties  have  had  to  be  overcome  owing  to  the  reticence 
of  the  natives,  their  ignorance  of  the  disease  as  such,  and  their  fear 
of  any  interference. 

At  first  great  difficulty  was  experienced  in  obtaining  true  histories 
of  the  cases  and  of  the  duration  of  the  illness.  Later,  when  the  con- 
fidence of  the  villagers  had  been  gained,  this  improved  somewhat. 
It  is  hoped  that  the  return  of  the  patients  cured  to  their  villages  will 
strengthen  their  confidence  and  make  it  easier  for  further  investiga- 
tion. 


126 


THE  GYNECOLOGICAL,  OBSTETRICAL  AND  SURGICAL 
ASPECTS  OF  PELLAGRA— A  PRELIMINARY  STUDY 

ELEANORA   B.    SAUNDERS^    M.  D. 
Assistant  Physician,  State  Hospital  for  the  Insane 

COLUMBIAj    S.    C. 

When  we  realize  that  the  Itahans  have  been  studying  pellagra  for 
one  hundred  and  seventy  years,  it  seems  impossible  to  advance  any 
new  theories  or  ideas  about  this  disease.  Still  certain  aspects  of  the 
problem  have  forced  themselves  upon  my  attention  during  the  last 
two  years  so  that  I  beg  to  ask  your  consideration  of  some  gynecolo- 
gical, obstetrical  and  surgical  phases  of  our  newly  recognized  malady. 
I  wish  to  report  briefly  a  series  of  cases  in  some  of  which  pellagra 
was  not  only  not  recognized,  but  did  not  manifest  itself  cutaneously 
till  after  surgical  intervention;  also  others  associated  with  menor- 
rhagia  and  post  partum  hemorrhage  and  some  cases  developing 
pellagra  after  parturition. 

Sir  Henry  Holland,  writing  upon  "The  Pellagra  in  Lombardy" 
in  1817,  says :  "In  females,  the  menstruation  is  generally  continued 
without  irregularity,"  but  such  has  not  been  the  fact  in  our  cases, 
as  the  majority  suffer  from  amenorrhea  or  menorrhagia.  The 
amenorrhoea  is  probably  due  to  the  anemia  secondary  to  the  dis- 
ease. In  these  cases  normal  menstruation  does  not  return  until 
either  the  patients  are  on  the  road  to  recovery  or  after  they  are  fully 
restored. 

Patients  suffering  from  menorrhagia  are  relieved  of  that  condi- 
tion by  a  recession  of  the  pellagrous  symptoms.  In  young  girls  and 
unmarried  women,  amenorrhea  is  the  more  common,  while  menor- 
rhagia and  metrorrhagia  are  more  often  the  rule  in  multiparous 
women.  The  flow  may  occur  at  the  regular  periods,  irregularly  or 
almost  continuously,  but  amenorrhea  is  most  frequent  in  our  pa- 
tients. Rather  than  read  a  long  and  possibly  wearisome  list  of  his- 
tories, I  have  endeavored  to  summarize  in  the  briefest  abstracts  the 
twenty-four  cases  that  form  the  basis  of  my  paper.  These  observa- 
tions are  based  upon  the  systematic  study  of  white  females  only. 

Case  i — 

Girls  eighteen  years  old,  typical  syndrome  of  eruption,  stomati- 
tis, diarrhea,  depression,  amenorrhea  for  months,  slow  recovery,  (not 
an  asylum  case). 


127 

Case  2 — 

Single,  twenty-six  years  of  age,  history  of  several  annual  attacks 
of  pellagra,  amenorrhea  throughout  every  attack,  very  red  tongue 
and  mouth,  great  fear  of  water,  pellagrous  dermatitis.  Later  pro- 
longed profuse  menstruation.  In  this  case  the  menstrual  abnor- 
malities were  entirely  due  to  pellagra.  Recovered,  (Private  pa- 
tient). 

Case  3 — 

Married,  forty-two  years  of  age,  ten  pregnancies.  During  the 
last  pregnancy  had  eruption,  fiery  tongue,  depression.  After  normal 
labor  as  the  doctor  was  leaving  the  house,  the  nurse  exclaimed, 
"The  patient  is  flooding."  A  very  severe  post-partum  hemorrhage 
followed  with  a  resulting  anemia  of  thirteen  months'  duration.  Re- 
covered.    (Private  case). 

Case  4 — 

Twenty-six  years  of  age,  single.  Became  depressed,  had  eruption 
and  menorrhagia  which  was  relieved  for  a  time  by  currettage.  Fin- 
ally menorrhagia  developed  with  delirium,  convulsions  and  death 
from  typhoid  pellagra.     (Treated  at  home.) 

Case  5 — 

Twenty-four  years  of  age,  single,  very  nervous,  "run  down"  and 
weak;  suffered  from  menstrual  disturbances,  including  marked 
metrorraghia.  Had  uterine  operation  without  benefit.  Eruption 
developed  later  and  was  followed  by  marked  depression,  necessitat- 
ing admission  to  State  Hospital.  On  admission  stomatitis,  diarrhea 
and  eruption.    Improved  mentally.    Discharged. 

There  is  often  a  very  annoying  pruritus  with  or  without  vaginal 
discharge.  These  patients  complain  bitterly  of  the  intolerable  itch- 
ing and  burning,  regardless  of  the  degree  of  inflammation.  The 
vulvar  mucous  membrane  often  shows  the  same  "stippled"  appear- 
ance as  the  tongue.  Small  hemorrhages,  such  as  are  observed  under 
the  epidermis  of  the  palms  and  soles  have  been  seen  under  the 
vaginal  and  vulvar  mucous  membrane  and  adjacent  skin. 

All  writers  have  emphasized  as  the  most  striking  pellagra  symp- 
tom the  development  of  dermatitis  on  the  exposed  surfaces  of  the 
body  and  ascribed  this  erythema  to  the  sun's  rays.  This  most  ob- 
vious but  really  least  important  symptom  probably  accounts  for  the 
fact  that  pellagra  has  been  recognized  in  American  dermatologies 


128 

while  omitted  from  other  text  books.  It  is  only  recently  that  some 
attention  has  been  given  to  the  evolution  of  pellagrous  inflammation 
upon  portions  of  the  body  not  subjected  to  the  sun's  influence;  such 
as  bony  prominences  and  folds  of  the  joints.  Here  the  cause  of  the 
hard  and  rough  skin  has  been  assigned  by  some  to  pressure.  ( Sand- 
with.) 

Description  of  these  lesions  upon  unexposed  surfaces  are  rare,  so 
that  I  take  the  liberty  of  quoting  at  length  from  a  recent  article  by 
Nicolas  and  Jambon  of  Lyons,  France.  (Annales  de  Dermatologie 
et  de  syphylographie,  1908.)  "Pellagrous  vulvitis  has  not  been 
described  up  to  the  present  by  vi^riters  with  the  frequency  it  deserves. 
Brault  of  Algiers,  however,  has  described  it  in  several  of  his  cases. 
When  we  ourselves  saw  it  for  the  first  time,  we  considered  it  com- 
mon intertrigo  due  to  the  lack  of  bathing.  But  the  establishment  of 
similar  lesions  in  other  cases  and  the  reading  of  Brault's  observa- 
tions, made  us  study  this  symptom  with  greater  care.  It  manifested 
itself  as  an  erythema,  very  acute,  slightly  painful,  giving  sensations 
of  smarting,  burning  and  occupying  the  whole  vulvar  region  as  well 
as  the  perineal,  the  anal  fold  and  the  internal  surfaces  of  the  labia 
majora,  internal  and  external,  are  erythematous  patches.  These 
lesions  are  oozing  and  take  on  a  pseudo-membranous  appearance. 
The  erythema  lessens  upon  the  labia  minora  and  ceases  completely 
at  the  vestibular  vaginal  commissure.  The  same  condition  exists 
at  the  anal  commissure,  the  mucous  membrance  of  which  does  not 
participate  in  the  inflammation.  The  invaded  regions  are  the  site 
of  an  infiltration  sufliciently  marked  and  then  maceration  of  the 
epidermis  rapidly  develops.  A  fetid  odor  is  given  oflf.  The  prog- 
nosis of  this  erythema  is  essentially  chronic  like  that  of  the  whole 
malady.  The  lesions  appear  at  about  the  same  time  as  the  skin  and 
buccal  manifestations.  They  do  not  exist  without  those  manifesta- 
tions, but  they  may  be  absent." 

My  own  observations  upon  cases  have  led  me  to  the  following 
conclusions; -some  of  which  verify  those  of  Brault  and  of  Nicolas 
and  Jambon.  From  the  vaginal  mucous  membrane  there  is  a  thick 
exudate  identical  in  appearance  with  the  viscid  secretion  so  often 
seen  in  the  mouths  of  pellagrins  and  frequently  not  only  suggesting 
but  really  regarded  as  salivation  (pyalism). 

There  is  also  often  a  very  profuse  exudate  from  the  vaginal  mu- 
cous membrane,  which  being  acrid  causes  a  maceration  of  the  skin. 
In  other  cases  a  distinct  excoriation  or  erosion  and  in  some  a  com- 
plete denudation  develops.    I,  too,  was  disposed  to  believe  it  due  to 


129 

untidiness  in  patients  and  from  very  acid  or  alkaline  urine,  but  ex- 
amination shows  the  urine  to  be  bland.  Here,  I  may  mention  that 
as  is  the  case  in  Italy  I  have  frequently  found  the  urine  of  pella- 
grins ammoniacal.  On  the  skin  about  the  perineum  are  areas  vary- 
ing in  size  from  very  small  spots  involving  almost  all  the  inner  side 
of  the  thighs,  extending  far  around  to  the  gluteal  regions  and 
reaching  in  some  cases  almost  to  the  knees.  This  area  is  always  very 
red,  swollen  and  oozes  constantly  a  profuse  sero-sanguinous  fluid. 
This  appearance  is  usually  seen  in  the  so-called  "wet"  cases  where 
the  skin  of  the  hands  and  other  parts  is  in  the  same  bullous  condi- 
tion. These  stigmata  of  pellagra  upon  the  unexposed  parts  of  the 
body  are  due,  of  course,  in  the  first  place  to  the  virulence  of  the  un- 
known poison,  since  they  are  not  seen  in  mild  cases.  Secondarily, 
the  inflammatory  exudate  produces  maceration  which  in  turn  further 
extends  the  zone  of  inflammation.  Here  also,  pressure  may  be  an 
element  in  these  cases.  I  may  mention  in  passing  that  colored  wo- 
men appear  to  be  more  prone  to  these  moist  pellagrous  lesions  than 
white  women.  This  applies  to  private  cases  as  well  as  to  asylum 
pellagrins.  Also  the  extent  of  the  dermatitis  and  the  degree  of 
pigmentation  seem  to  have  a  prognostic  value  or  a  direct  relationship 
to  the  subsequent  liability  to  the  development  of  more  serious  mental 
symptoms  and  of  typhoid  pellagra. 

The  vaginal  mucous  membrane  of  these  cases  shows  the  same 
red  inflamed  condition,  and  here  too  is  seen  a  peculiar  mottled 
appearance  as  of  small  hemorrhages  under  the  membrane.  Cases 
examined  at  the  State  Hospital  show  the  vaginal  mucous  membrane 
to  be  inflamed  in  equal  degree  with  that  of  the  buccal  and  other 
mucous  membranes. 

Very  decided  pain  is  felt  in  the  region  of  the  ovaries  at  the  men- 
strual period  and  irregularly.  Autopsies  show  a  red  congested 
ovary,  the  whole  body  of  the  ovary  being  involved.  Pregnancy  by 
its  debilitating  effects,  has  its  weight  here  and  objective  pellagra  has 
at  least  been  hastened  or  aggravated  by  this  great  physical  strain. 
Frequent  pregnancies  and  prolonged  lactation  by  lowering  vital 
resistance  may  alter  the  character  of  the  case.  "The  considerable 
rate  of  still  births,"  says  Marie,  writing  of  pellagra  among  the 
Egyptian  Arabs,  "would  not  exist  without  this  great  malady."  In 
another  place  Marie  says,  basing  his  remarks  upon  Lombroso's  ob- 
servations :  "In  hereditary  pellagrous  women  are  noticed  atrophy  of 
the  breasts,  irregularity  or  absence  of  the  catemenia,  which  is  some- 
times followed  by  a  painful  metrorrhagia.    Calderini  notes  dysuria 

9— p.  c. 


I30 

in  57  per  cent,  of  the  females  pellagrins,  amenorrhea  of  50  per  cent. ; 
leucorrhea  in  50  per  cent,  and  abortion  in  17  per  cent.  Many  cases 
suffer  from  subjective  sensations  of  uterine  inflammation  or  dis- 
placements without  objective  signs.  A  robust  country  woman  in 
the  hospital  at  Verona,  thirty-one  years  old,  the  mother  of  five  chil- 
dren, complained  of  violent  pain  on  urination  and  a  sensation  of 
weight  in  the  uterus  "as  if  it  were  made  of  lead,"  with  burning  at 
the  cervix  uteri.  She  would  not  tolerate  a  speculum  for  examina- 
tion but  was  treated  a  long  while  for  metritis.  Finally  she  began  to 
complain  of  epigrastric  swelling,  burning  on  the  back,  alternate  sen- 
sations of  hot  and  cold  and  had  diplopia;  later  she  developed  a  mel- 
ancholic mutism  without  adequate  cause.  It  was  then  thought  that 
perhaps  the  uterine  symptoms  might  be  of  a  pellagrous  nature.  A 
careful  examination  with  the  speculum,  however,  showed  no  trace 
of  metritis.    It  turned  out  to  be  a  case  of  unrecognized  pellgra." 

Other  authorities  assert  that  "the  female  sex,  as  we  have  seen,  is 
decidedly  more  disposed  to  pellagra,  and  this  arises  probably  from  the 
fact,  that  especially  the  nervous  system  of  women  is  easily  affected, 
and  that  they  are  more  overburdened  than  the  men,  particularly  in 
the  country  population  of  Roumania  by  work  and  child  bearing. 
Indeed  the  greatest  frequency  of  pellagra  in  women  begins  only 
after  the  20th  year  and  continues  up  to  the  40th,  accordingly,  in  the 
time  of  the  sexual  life  of  the  women.  In  general  most  of  the  pella- 
grins are  found  to  be  within  this  period  of  years,  although  many 
children  are  pellagrous.  This  is  evidently  due  to  the  fact  that  the 
rural  population  in  more  under  a  strain  in  these  years  20  to  40,  while 
their  diet  is  not  sufficient  for  the  amount  of  the  work  done."  (Babes 
and  Sion.) 

Case  6 — 

Married  ten  years,  28  years  old,  first  pregnancy  ending  about 
twelve  months  ago.  Three  weeks  after  child-birth  she  suffered  with 
sore  mouth,  but  had  nervous  symptoms  before  confinement.  Stoma- 
titis, diarrhoea  excitement,  later  eruption  on  hands,  which  grew  worse. 
Patient  lost  ground  physically  and  mentally,  became  suicidal  and 
consequently  was  admitted  to  asylum.  Has  run  a  typical  course  and 
has  been  very  suicidal,  and  at  present  all  symptoms  are  better  except 
the  mental.     Still  under  observation. 

Prolonged  lactation  by  enervating  influence  may  cause  a  depres- 
sion amounting  to  resistive  melancholia.  Such  cases  becoming  pel- 
lagrous usually  complain  of  "getting  run  down,"  and  are  thin  and 


131 

nervous.  Diarrhea  sets  in  and  the  eruption  completes  the  picture. 
In  time  it  is  to  be  hoped  that  we  shall  learn  to  diagnose,  or  at  least 
to  suspect  the  presence  of  pellagra  in  debilitated  and  nervous  women 
without  waiting  for  the  appearance  of  the  eruption. 

Case  7 — 

A  decided  blonde,  age  32  years,  second  child  three  years  of  age, 
prolonged  lactation  during  the  summer  of  1908,  was  much  debili- 
tated and  "run  down."  Eruption  appeared  later,  but  she  continued 
to  nurse  the  child  until  admitted  to  asylum  in  April,  1909.  Since 
admission  she  has  shown  great  mental  instability,  is  moody,  emo- 
tional, and  at  times'  very  noisy,  has  bad  diarrhea  and  eruption,  which 
is  exceptional  in  that  it  extended  far  above  the  elbows.  (Is  still 
under  treatment). 

Frequent  child-bearing  by  sapping  the  strength  of  these  nervous 
patients  seems  to  play  its  part  as  a  predisposing  cause  in  the  devel- 
opment of  the  pellagra  syndrome.  Already  Strambio  about  1790,  as 
noted  by  Babes  and  Sion,  had  observed  that  gestation  gave  occasion 
to  the  breaking  out  of  pellagra.  He  also  observed  cases  in  which 
pellagra  appeared  only  during  gestation  and  lactation,  and  then 
receded. 

Case  8 — 

Married,  age  49,  history  of  many  and  very  rapid  pregnancies, 
always  run  down,  had  eruption  several  years.  Very  depressed.  Upon 
admission  to  asylum  had  dermatitis  and  diarrhoea.  Abject  depres- 
sion marked  this  case.  She  suffered  from  menorrhagia.  Finally 
she  made  a  complete  recovery.    Discharged. 

Surgical  operations  acting  as  trauma  develop  latent  pellagra  and 
lowering  the  resistance  aggravate  or  hasten  its  course.  In  the  early 
cases,  we  have  all  the  train  of  symptoms :  backache,  pelvic  distress, 
head-ache,  bearing  down  pains,  weakness,  lassitude,  emaciation, 
ovarian  and  menstrual  disturbances,  which  are  seen  in  pelvic  disease, 
for,  as  Manton  well  says,  mental  symptoms  are  present  in  gynecolog- 
ical cases.  When  the  eruption  is  not  present,  the  unsuspecting 
doctor  or  consultant  is  most  likely  to  pronounce  the  case  pelvic  and 
treat  the  symptoms  as  pointing  to  a  primary  gynecological  trouble 
without  thinking  of  its  being  a  part  of  the  pellagrous  symptomatology. 
Here,  too,  the  mental  depression  is  regarded  as  merely  a  symptom 
of  the  pelvic  disease  and  operation  or  special  treatment  is  advised. 
The  consultant  neglects  to  ask  for  a  history  of  the  eruption  for  one 


132 

year  or  maybe  for  four  or  five  years,  and  at  the  same  time  there  is 
perhaps  a  very  red  tongue,  swollen  and  indented  with  stomatitis 
which  he  overlooks  or  diagnoses  and  treats  as  ptyalism  and  disre- 
gards the  severe  wasting  diarrhoea  with  increased  knee  jerks,  pupil- 
lary anomalies,  marked  atheroma,  enlarged  epitrochlears  dorsal  pain 
and  "nervous  dyspepsia."  I  am  compelled  to  say  that  cases  of  so- 
called  post-operative  insanity  admitted  to  this  asylum  point  to  this 
conclusion,  for  in  the  spring  and  summer  of  1908,  we  had,  as  we 
do  every  year  many  such  cases  which  showed  all  these  symptoms  of 
early  pellagra  and  gave  histories  of  former  eruptions  and  diarrhoea. 
To  cite  an  unusual  occurrence  but  striking  coincidence,  in  one  week 
we  admitted  five  cases  of  pellagra  which  had  been  operated  on  for 
gynecological  trouble  within  the  preceding  two  months  and  all  of 
these  at  the  time  of  admission  had  or  developed  within  a  month,  the 
typical  objective  pellagrous  stigmata.  Three  of  these  five  died  and 
two  went  home,  recovered. 

The  uterine  hemorrhage,  irregular  or  continuous,  accompanied  or 
not  by  a  vaginal  discharge,  especially  in  women  of  advanced  years, 
will  alarm  the  doctor,  and  even  though  there  be  other  symptoms 
pointing  to  pellagra,  he  immediately  diagnoses  cancer  and  strongly 
urges  the  family  to  have  an  hysterectomy  done.  Such  pellagrins 
have  been  subjected  to  operations  for  cancer  in  this  country  and 
abroad.  The  gastric  disturbances  call  the  attention  to  the  stomach, 
and  ulcer  or  cancer  is  thought  of  at  once.  When  an  exploratory 
operation  is  done,  the  stomach  is  seen  to  be  in  the  same  inflamed 
condition  as  the  mouth  and  other  mucous  membranes.  Even  the 
kidney  does  not  escape  surgical  invasion.  The  absorption  of  fat 
accompanying  the  emaciation  may  be  the  cause  of  a  so-called  float- 
ing kidney  and  perhaps,  too,  it  will  partially  adjust  itself  and  waiting 
for  a  time  till  the  patient  has  recovered  from  pellagra,  can  in  many 
cases  be  put  off  and  watched  closely  for  alarming  symptoms  of 
any  kind  due  to  the  condition  of  the  kidney. 

The  point  that  I  wish  to  make  is  to  suggest  that  hereafter  as  the 
recognized  pellagra  zone  widens,  when  confronted  with  a  nervous 
or  mental  case  in  a  woman  for  whose  relief  their  intervention  is 
sought,  surgeons  and  gynecologists  must  reckon  with  the  pellagra 
syndrome  and  at  least  temporize  in  trying  to  relieve  the  pellagrous 
symptoms  and  thus  prepare  the  patients  for  the  surgical  ordeal 
before  resorting  to  an  operation.  When  we  fully  realize  how  unequal 
is  the  struggle  against  pellagra  alone,  how  can  we  subject  already 


133 

enfeebled  patients  to  the  ordeal  of  a  capital  operation  to  be  followed 
by  the  combined  effects  of  pellagra  and  trauma  ? 

The  following  cases  illustrate  my  contention.  These  cases,  one 
and  all,  had  had  surgical  operations  to  relieve  pelvic  symptoms  and 
were  brought  to  the  Asylum  very  soon  after  these  operations  had 
failed  to  relieve  the  symptoms  delineated. 

Case  9 — 

Single,  twenty-four  years  old  when  •admitted  to  the  asylum.  Pro- 
longed ill  health  accompanied  by  ovarian  symptoms  for  which  ovari- 
otomy was  done,  soon  followed  by  pellagrous  dermatitis  with  refusal 
of  food,  diarrhoea,  mutism,  ideas  of  poison,  exhaustion,  emaciation, 
death. 


Case 

Married,  aged  43  years.  Very  acute  ovarian  affection,  ovariotomy 
followed  by  pellagrous  rash,  stomatitis,  diarrhoea,  very  excited, 
admitted  to  asylum,  died  after  three  weeks  of  delirium  from  typhoid 
pellagra.    Temperature  107  before  death. 

Case  ii — 

Single,  age  25,  always  suffered  from  ill-health  and  dysmenorrhea. 
Developed  dementia  precox,  ovariotomy,  pupura,  admitted  to  the 
asylum,  diarrhoea,  catalepsy,  resistive,  refusal  of  food,  emaciation, 
sudden  death. 

Case  12 — 

Single,  24  years  of  age,  mother  insane  with  history  of  unrecog- 
nized pellagra.  Ovariotomy  for  "female  trouble,"  after  which  she 
was  admitted  to  asylum  and  in  a  few  days  showed  a  pellagrous 
eruption,  stomatitis,  diarrhoea.  After  months  of  treatment  for  the 
mental  trouble,  was  discharged  recovered. 

Case  13 — 

Married,  twenty-six,  ovariotomy  for  a  depression  of  many  months' 
duration  but  had  also  dermatitis,  diarrhoea,  great  emaciation  and 
lassitude,  mutism,  greatly  apprehensive.  Admitted  to  the  asylum 
very  prostrated,  being  an  apparently  hopeless  case.  Recovery  after 
many  months'  residence  in  asylum. 


134 

Case  14 — 

Married,  27  years  of  age,  female  trouble,  prolonged  lactation, 
depression,  uterine  operation,  partial  recovery  but  soon  relapsed, 
depression,  noisy  at  times,  rapid  emaciation,  dermatitis,  diarrhoea, 
admitted  to  the  asylum,  eruption  still  present,  catatonic,  spastic, 
mutism,  dilated  pupils.     Still  under  treatment. 

Case  15 — 

Married,  23  years  of  age,  female  trouble,  weak,  nervous.  Hys- 
terectomy followed  by  excitement.  Admitted  to  the  asylum  with 
diarrhoea,  refusal  of  food,  dermatitis,  great  emaciation,  suicidal, 
death  from  exhaustion. 

Case  16 — 

jMarried,  forty-one,  repeated  gynecological  operations  for  ''ner- 
vousness and  female  trouble,"  loss  of  appetite,  petulant  disposition, 
diarrhoea,  indecency.  Committed  to  asylum,  soon  developed  stom- 
atitis, eruption  and  emaciation.  Removed  to  private  asylum.  Died 
from  pellagra. 

Case  17— 

Married,  fifty-eight,  severe  pains  in  ovarian  region,  nervousness, 
ovariotomy,  excited,  admitted  to  asylum,  emaciation,  eruption,  delu- 
sions of  poison,  death. 

Case  18 — 

Single,  twenty-one,  history  of  nervousness  and  flooding.  Opera- 
tion. No  improvement.  Another  operation  was  advised,  but  was 
refused.  Recovered  from  menorrhagia.  Suffering  from  amenor- 
rhea and  mental  symptoms,  was  admitted  to  asylum,  a  typical  pel* 
lagrin.    Recovered. 

Case  19 — 

Married,  forty  years  old,  diarrhoea,  digestive  disturbances,  rash, 
depression,  ovariotomy,  relapse  for  two  years,  exhaustion,  death. 
(Never  admitted  to  asylum). 

Case  20 — 

Married,  twenty-nine  years  old,  eruption,  stomatitis,  diarrhoea, 
digestive  disturbances,  stomach  contents  suggested  ulcer.  Explora- 
tory operation  showed  an  inflamed  and  a  very  red  stomach.  One 
week  after  operation  red  rash  on  hands  and  blebs,  followed  by 
desquamation.  Recovered.  (Mental  depression  not  sufficient  to  call 
for  asylum  treatment). 


135 

Case  21 — 

Married,  thirty-two  years  old,  diarrhoea,  dilated  pupils,  depres- 
sion, emaciation,  operation  for  floating  kidney.  Symptoms  of  de- 
pression, nervousness  and  not  benefited  mentally  by  operation, 
admitted  to  asylum  with  diarrhoea  and  typical  stomatitis  and  erup- 
tion.    Still  under  treatment. 

Case  22 — 

Single,  thirty-two  years  old,  "female  trouble,"  hypochondriacal, 
nervous,  ovariotomy,  emaciation,  digestive  disturbances,  persistent 
vomiting  and  diarrhoea,  admitted  to  asylum  for  treatment  in  almost 
dying  condition,  carphologia,  severe  diarrhoea  prostration  with  large 
moist  rales.     Prolonged  course.     Recovery. 

Case  23 — 

Single,  twenty-four  years  old,  after  months  of  declining  health, 
ovariotomy  was  done  to  try  to  relieve  her  trouble.  Emaciated, 
rigid,  very  excited,  stomatitis,  rapid  development  of  eruption,  very 
wild  delirium.  Death  in  a  few  weeks  after  admission  to  asylum 
from  typhoid  pellagra. 

Case  24 — 

Married,  forty-four  years  old,  hysterectomy  for  hemorrhage  and 
discharge  accompanied  by  cachexia  and  declining  health,  excited, 
restless.  Admitted -to  the  asylum,  very  sclerotic,  varicose  veins, 
large  simple  goitre,  diarrhoea,  eruption,  death. 

To  sum  up  my  observations  and  reading  upon  the  aspects  of  pel- 
lagra embraced  in  this  paper:  Of  the  twenty- four  cases  reported, 
four  are  still  under  treatment,  10  recovered,  10  died. 

General — In  America  and  Roumania  the  female  sex  is  more 
liable  to  pellagra,  the  period  of  greatest  incidence  being  the  20th  to 
40th  year.  Pregnant  women  suffering  from  pellagra  are  liable 
to  abortion  (17  per  cent.)  to  give  birth  to  still-born  infants  and 
at  delivery  to  post-partum  hemorrhage.  Gestation  and  lactation, 
especially  when  frequent,  predispose  to  pellagra.  Parturition  is 
often  an  exciting  cause  for  the  outbreak  of  the  dermatitis.  Amenor- 
rhea and  leucorrhea  occur  in  50  per  cent,  of  the  cases  and  dysuria 
in  57  per  cent.  Unmarried  female  pellagrins  are  more  subject  to 
amenorrhea.  Multoparous  pellagrins  are  liable  to  menorrhagia,  and 
present  symptoms  suggesting  cancer.  Their  subjective  symptoms 
may  point  to  diseases  of  the  pelvic  organs  and  require  careful 
examination  for  their  exclusion. 


136 

Not  uncommon  are  vulvitis,  vulvo-vaginitis,  cervical  erosions, 
endo-cervicitis  and  endometritis,  ovarian  neuralgia  and  inflamma- 
tion, maceration  and  denudation  of  adjacent  skin  upon  the  thigh 
and  in  perineal  and  anal  region,  especially  in  "wet"  cases. 

Surgical — A  surgical  operation  may  bring  out  latent  pellagra. 
Diseases  of  kidney  are  simulated  and  may  be  primary  or  secondary. 

Stomach  symptoms  are  often  so  severe  as  to  require  attention  and 
rigid  diagnostic  methods.  Care  should  be  exercised  to  prevent 
needless  surgical  or  other  treatment. 

Other  subjective  symptoms  may  annoy  the  patient  to  such  an 
extent  as  to  demand  treatment.  Pellagrins  often  complain  of 
symptoms  suggestive  of  hemorrhoids  when  it  is  really  proctitis,  a 
part  of  the  general  inflammation  of  intestinal  mucose  and  adjoining 
epidermis. 

In  essence,  pellagra  may  be  a  tropho-neurosis,  but  in  women  the 
pelvic  organs  are  especially  subject  to  the  invasion  of  the  unknown 
poison,  is  a  fact  demanding  wider  recognition  as  well  as  further 
study. 

Of  course,  ours  is  the  dark  side.  In  our  asylum  life  we  see  a 
few  failures  among  many  brilliant  surgical  successes,  but  the  above 
surely  point  to  the  fact  that  in  the  initial  stages,  especially  where  the 
symptoms  are  not  very  well  marked  and  where  there  is  much  point- 
ing to  pellagra  as  well  as  to  other  diseases,  a  very  careful  differential 
diagnosis  should  be  made  and  care  given  to  other  than  the  pelvic 
symptoms  of  these  cases.  If  possible,  relieve  the  primary  disorder, 
pellagra,  before  resorting  to  radical  operations,  which  at  best  cannot 
cure  pellagra,  and  will  probably  only  increase  the  already  lethal 
tendency.  Not  much  will  be  lost  in  waiting  for  a  time,  at  the  expira- 
tion of  which  the  symptoms  may  have  been  relieved,  or  the  pellagra 
erythema  now  so  necessary  for  diagnosis  have  appeared  in  full 
efliloresence. 

Cases  of  pellagra  on  account  of  their  debilitated  condition  are 
prone  to  other  diseases  and  are  subject  to  "incidentals"  which  do 
require  surgical  intervention.  These,  of  course,  demand  and  should 
have  prompt  attention.  But  after  granting  all  this,  I  am  forced  to 
believe  that  the  majority  of  such  cases  should  be  treated  not  as 
having  a  primary  organic  pelvic  disease,  but  as  suffering  from  func- 
tional or  symptomatic  disorders,  and,  furthermore,  that  the  gyneco- 
logical, obstetrical  and  surgical  aspects  of  pellagra  are  factors  which 
not  only  the  general  practitioner  must  consider,  but  with  which  spe- 
cialists of  several  kinds  who  live  in  the  "pellagra  zone"  must  here- 
after reckon  for  the  real  welfare  of  their  Datients. 


137 


PELLAGRA— ITS   RELATION   TO   INSANITY  AND   CER- 
TAIN NERVOUS  DISEASES 

J.   W.  MOBLEY,   M.  D. 

MILLEDGBVILLHj    GA. 

Much  has  been  written  in  the  last  two  years  on  pellagra,  and 
especially  pellagra  in  the  South. 

The  daily  newspapers  have  given  considerable  attention  to  the 
subject,  and  agitation  of  this  malady  has  arisen  from  many  other 
sources  since  its  general  recognition  by  the  medical  profession  in  the 
South. 

The  purport  of  this  paper  is  not  so  much  to  deal  with  the  history  of 
pellagra,  but  to  present  the  disease,  as  the  writer  sees  it,  in  its  many 
sided  clinical  aspects.  At  the  very  outset,  we  are  drawn  into  conten- 
tion with  a  serious  problem.  There  is  no  further  question  as  to  the 
existence  of  pellagra  throughout  the  South. 

It  is  here  in  its  true  and  allied  forms,  confronting  us  with  such  an 
awful  clinical  picture  as  to  carry  death  and  despair  in  its  very  name. 
The  alienist  looks  back  with  regrets  upon  the  mortality  of  this 
scourge  in  hospitals  for  the  insane.  He  is  made  to  reflect  with  deep 
concern  for  the  future  of  his  race,  when  he  observes  the  powerful 
impress  of  this  disease  upon  the  mind  and  nervous  system.  The  gen- 
eral practitioner  is  not  so  much  called  upon  to  consider  pellagra  in 
its  relation  to  insanity.  On  the  alienist  rests  the  moral  duty  of  warn- 
ing his  people  against  an  infection  which,  once  firmly  rooted,  will 
manifest  its  baneful  influence  forever  upon  the  human  family. 

Discouraging  enough  would  it  be  if  each  individual  case  repre- 
sented a  morbid  entity  unto  itself.  The  picture  becomes  more  serious, 
however,  when  we  contemplate  the  role  which  pellagra  plays  in  the 
chain  of  heredity.  Its  poisoning  effects  are  not  spent  alone  upon  the 
individual  subject,  but  like  tuberculosis,  it  transmits  a  morbid  inher- 
itance to  the  recipients  of  its  toxines. 

I  desire  here,  gentlemen,  to  deeply  impress  upon  you  the  evil  which 
this  disease  must  represent  as  a  vicious  factor  in  our  social  system. 
What  would  the  world  give  today  if  it  could  recall  the  propagation 
of  idiots?  What  a  stain  could  be  removed  from  medical  science  if 
the  life-history  and  management  of  tuberculosis  might  be  reviewed. 
Many  already  are  the  deteriorating  forces  which  prevail  against  our 


138 

race.     Shall  we  sit  idly  by  and  allow  the  ravages  of  this  insidious 
monster  to  sap,  unbridled,  the  vitality  of  our  future  generations  ? 

Upon  this  distinguished  conference  rests  the  responsibility  of 
inaugurating  measures  looking  to  the  suppression  and  control  of  this 
rapidly  increasing  malady. 

PREVALENCE.   - 

The  report  of  the  Public  Health  and  Marine  Hospital  Service  for 
1909  will  show  that  Dr.  Gray,  of  New  York,  and  Dr.  Tyler,  of 
Massachusetts,  reported  two  probable  cases  of  pellagra  forty-five 
(45)  years  ago.  I  am  informed  that  both  of  these  gentlemen  were 
alienists,  and  you  are  here  reminded  again  of  the  splendid  oppor- 
tunity offered  physicians  to  hospitals  for  the  insane  to  observe  these 
cases.  It  is,  indeed,  hard  to  account  for  the  stuporous  lapse  of  time 
in  which  forty  years  or  more  passed  away  without  the  record  of  a 
single  case  in  the  United  States.  Harris,  of  Georgia,  and  Shewell, 
of  Chicago,  finally  reported  a  case  each  in  1902.  Following 
the  last  two  mentioned  cases,  there  was  another  lapse  of  comment 
upon  the  disease  until  1906- 1909,  when  there  seems  to  have  been 
an  epidemic  of  observations  as  well  as  cases  reported. 

Probably  to  Babcock,  of  South  Carolina,  is  due  the  greatest  credit 
for  the  most  thorough  report  of  cases  in  the  South,  and  a  complete 
bibliography  of  the  disease  in  this  country. 

No  doubt,  pellagra  has  been  steadily  on  the  increase  in  the  United 
States  since  i860.  The  impression  prevailing  that  it  was  a  disease 
indigenous  to  foreign  countries,  not  much  vigilance  was  given  to  its 
detection. 

It  is  true  that  many  clinical  conditions  may  have  been  confused 
with  pellagra,  more  especially  certain  nervous  diseases  attended  by 
secondary  trophic  symptoms,  dependent  upon  faulty  innervation,  but 
such  are  not  sufficient  excuses  to  warrant  so  great  an  oversight  on 
the  part  of  the  medical  profession. 

ETIOLOGY. 

The  cause  of  pellagra  will  probably  be  found  in  both  general  and 
specific  factors.  Just  to  what  extent,  if  at  all,  they  operate  together, 
we  are  unable  to  say.  The  various  clinical  aspects  of  the  disease, 
however,  would  justify  us  in  considering  its  etiology  under  several 
headings. 


139 

First. — Is  pellagra  produced  only  by  a  specific  organism,  and  its 
toxines  ? 

In  considering  a  specific  factor  as  the  sole  cause  of  pellagra,  we  are 
brought  to  face  with  many  conditions  which  speak  both  for  and 
against  this  etiology.  The  labors  of  the  very  best  men  in  this  country 
and  abroad  have  been  surrounded  with  doubts  and  practical  inconsis- 
tencies, but  have  ultimately,  and,  with  some  degree  of  reluctance, 
converged  into  the  opinion  expressed  by  the  famous  Italian  professor. 
Dr.  Lombroso — that  a  fungus  growing  upon  maize  produces  a 
toxine  which  causes  the  disease. 

Other  specific  factors  are  shown  in  the  protozoan  theory,  which  so 
closely  allies  syphilis  with  pellagra  as  to  make  their  clinical  picture 
at  times  quite  similar.  The  peculiar  cell  observed  by  Dr.  Cross,  of 
Georgia,  with  a  chlorophyle-like  content  is  on  the  side  of  a  specific 
infection.  He  describes  these  cells  as  about  the  size  of  hookworm 
eggs,  either  round  or  oval  in  shape.  He  suggests  that  they  may 
have  been  altered  epithelial  cells,  but  their  morphology  seemed  to 
be  unchanged. 

The  specific  fungus  (aspergelli)  which  grows  upon  corn  will  also 
grow  on  cheese,  and  may  account  for  the  disease  in  many  instances, 
where  the  history  of  a  corn  free  menu  is  obtained.  The  confusion 
and  tonic  muscular  state,  known  as  "blind  staggers,"  incident  to 
horses  that  are  supposed  to  have  eaten  molded  corn,  indicates  a 
clinical  phenomenon  of  vicious  infection  and  specific  origin.  Brown 
and  Low  report  a  case  as  having  occurred  in  a  shopwoman  from  the 
frequent  taking  of  raw  oatmeal  and  rice.  Maize  seems  to  have  played 
no  part  in  the  production  of  this  case. 

Much  more  evidence  might  be  cited  in  favor  of  a  specific  etiology, 
but  as  this  theory  does  not  prevail  unanimously  in  this  country,  and 
more  particularly  in  the  South,  we  will  proceed  to  other  factors  yet 
to  be  considered. 

Secondly. — Is  the  disease  caused  by  the  toxine  of  a  specific  organ- 
ism, operating  only  in  the  presence  of  a  peculiar  morbid  predispo- 
sition, racial  peculiarity?  Or  does  any  latent  or  active  pathological 
state  favor  its  development? 

In  studying  the  causative  factors  of  pellagra  from  this  viewpoint, 
we  are  brought  to  face  with  inherited  pathological  tendencies  which 
cover  a  broad  field  in  general  medicine.  Are  certain  individuals 
immune,  or  are  all  classes  susceptible  to  the  infection?  The  clinical 
behavior  of  the  diesase  opens  this  query,  but  I  shall  not  attempt  to 
discuss  it  here.     Certainly  an  immunity  does  not  appear  to  develop 


I40 

by  virtue  of  previous  attacks,  as  competent  observation  will  point  to 
the  conclusion  of  an  incurable  malady.  The  negro  female  in  Georgia 
seems  to  be  the  selective  host.  The  explanation  of  the  apparent  pro- 
clivity for  this  race  is  untenable  unless  explained  in  the  deteriorating 
phenomena  which  marks  so  great  a  decline  in  the  generic  purity  of 
this  class  since  their  so-called  freedom.  Apropos  of  this  idea — impres- 
sive are  the  facts  that  disclose  the  alarming  increase  of  syphilis,  tuber- 
culosis and  insanity  in  the  negro  race  of  Georgia  since  their  emanci- 
pation. Dr.  T.  O.  Powell,  former  Superintendent  of  the  State  Hos- 
pital, in  an  able  paper,  shows  that  there  were  only  forty- four  (44) 
insane  negroes  in  the  State  of  Georgia  up  to  i860.  Previous  to  this 
time  they  enjoyed  splendid  health,  and  tuberculosis  and  insanity  were 
exceedingly  rare  among  their  race.  These  forty- four  insane  negroes 
occurred  in  a  population  of  465,698,  representing  approximately  one 
insane  to  every  10,584  of  negro  inhabitants.  The  succeeding  ten 
years  show  an  increase  of  insanity  in  the  negro  to  one  in  every  4,225, 
with  a  colored  population  of  545,142.  The  census  of  1890  gives  the 
total  negro  population  in  Georgia  at  858,815 — the  number  of  colored 
insane  at  910;  advancing  the  ratio  in  thirty  years  from  one  to  every 
10,584  to  one  to  every  943  of  negro  inhabitants. 

Georgia  may  be  accepted  as  a  fair  index  to  the  social,  physical  and 
mental  condition  of  the  negro  in  the  South.  Syphilis  and  tuber- 
culosis, fraught  with  their  chain  of  moral  and  physical  deterioration, 
have  progressed  parri-passu  with  insanity  in  the  Southern  States 
since  1864,  and  should  be  considered  here,  especially,  in  relation  to 
pellagra.  These  diseases,  so  infrequent  in  the  days  of  slavery,  are 
now  so  common  as  to  represent  the  principal  chronic  maladies  from 
which  the  negro  suffers.  Interesting  will  it  be  to  note  here  that  the 
post-mortem  records  of  the  pathological  laboratory  of  the  State  Hos- 
pital for  Insane  of  Georgia  will  show  that  out  of  one  hundred  unse- 
lected  necropsys  about  ten  (10)  per  cent,  of  patients  dying  probably 
of  pellagra,  manifested  lesions  also  of  localized  or  general  tubercu- 
losis. If,  on  the  contrary,  we  presume  that  death  in  these  cases  was 
caused  from  tuberculosis,  then  a  like  per  cent,  exhibited  symptoms 
and  morbid  changes  suggestive  of  pellagra.  The  association  of  the 
two  diseases  are,  to  the  author,  too  frequent  to  pass  unnoticed.  The 
microscopic  findings  further  show  areas  of  syphilitic  necrosis, 
together  with  the  gross  tubercular  changes  in  some  of  these  cases. 

The  anatomical  diagnosis  of  the  majority  of  these  cases  appearing 
on  the  records  as  tubercular  enteritis. 

Considering  the  fact  that  pellagra  is  a  chronic,  progressive  disease ; 


141 

considering  the  fact  of  its  frequent  association  with  syphilis  and 
tuberculosis ;  and  considering  the  relationship  of  syphilis  to  certain 
chronic  nervous  diseases,  as  paresis  and  tabes — are  we  not  justified 
in  suspecting  the  existence  of  a  morbid  and  etiological  equivalent 
in  the  three  conditions  ? 

The  basic  principle  of  perfect  health  is  pure  blood  and  an  untainted 
physical  make-up,  and  while  each  individual  may  possess  an  inde- 
pendent reaction  index  both  in  health  and  disease,  yet,  the  impress 
of  chronic  morbid  factors,  operating  through  generations,  must 
finally  be  expressed  in  a  reduction  of  the  health  standard,  in  the  scale 
of  human  life. 

The  influence  of  crossing  in  the  negro  has  brought  as  its  product 
an  hybrid  type,  with  a  weakened  vital  resistance.  The  most  potent 
etiological  factor  in  the  production  of  insanity  is  insanity  itself ;  the 
same  may  be  said  of  tuberculosis.  The  scientists  tell  us  that  neither 
of  these  diseases  are  transmitted  as  such ;  but  no  student  of  anthro- 
pology would  attempt  to  deny  their  destructive  effect  upon  the  moral 
and  organic  continuity  of  the  human  race. 

As  an  hereditary  factor,  pellagra  possibly  possesses,  along  with 
insanity  and  certain  other  chronic  organic  diseases,  an  etiological 
equivalent  in  its  own  production. 

Among  other  contributing  causes  in  the  production  of  pellagra,  I 
feel  compelled  to  mention  certain  intestinal  parasites.  Dr.  Willets, 
Pathologist  to  the  Georgia  State  Sanitarium,  has  shown  that  out  of 
five  hundred  unselected  insane  negro  females,  thirty-five  had  pel- 
lagra. The  fecal  examinations  of  the  entire  number  (500)  disclosed 
the  fact  that  50  per  cent,  were  infected  with  some  form  of  intestinal 
parasite,  the  percentage  and  name  of  each  respective  parasite  being 
given  in  the  table  below: 
Number 

Negroes   Infections.  Ascaris.  Trichuris.  Strongy-  Uncinaria  Hymeno- 
Examined.  loides.  lepis. 

500  50%         28.2         40.2  18.2  1 1.8  0.2 

Pellagra. 

35  40%  8.57       17.14  25.71         20.0  2.86 

The  thirty-five  pellagra  cases,  of  course,  are  included  in  the  total 
number  examined ;  that  is,  five  hundred. 

You  will  observe  from  the  table  that  the  highest  per  cent,  of 
infection  in  the  pellagra  cases  is  from  strongyloides  and  uncinaria. 
These  parasites  are  both  blood  suckers,  and  are  quite  hard  to  dis- 


142 

lodge  from  the  intestinal  mucosa.    Whether  their  dinical  significance 
extends  beyond  this  scope,  I  am  unable  to  say. 

I  do  not  regard  pauperism,  per  se,  of  any  value  in  the  production  of 
pellagra,  aside  from  the  unfavorable  conditions  of  habitation ;  neither 
has  the  effect  of  the  sun  rays  been  satisfactorily  analyzed.  The  ques- 
tion of  contagion  received  some  support  through  the  peculiar  devel- 
opment of  the  disease  among  recent  admits  to  hospitals  for  the  insane. 

Dr.  N.  P.  Walker,  of  the  Georgia  State  Sanitarium,  reports  that 
out  of  eighty-nine  (89)  cases  of  pellagra,  among  the  insane  colored 
females,  only  nineteen  or  twenty-one  per  cent,  were  infected  with 
the  disease  at  the  time  of  admission.  The  remaining  seventy  (70) 
cases  exhibited  the  first  known  symptoms  of  pellagra  after  admis- 
sion. 

The  table  below  shows  approximately  the  time  of  first  known 
symptoms  after  admission,  in  the  colored  female  cases  referred  to : 
Months  Months  Months 

One  to  four  Five  to  eight"  7 

27  II  Nine  to  twelve 

Unknown  One  to  two  years         One    case    ten    years 

4  20  after  admission. 

This  table  may  be  accepted  as  representing  fairly  correctly  the 
status  of  the  (80)  cases,  more  or  less,  of  pellagra  occurring  among 
the  white  patients  of  the  Georgia  State  Sanitarium  in  the  last  two 
years. 

In  my  opinion,  the  records  of  all  hospitals  for  the  insane  in  the 
United  States  will  show  that  50  to  75  per  cent,  of  pellagrous  cases 
exhibit  the  first  known  definite  symptoms  of  the  disease  after  admis- 
sion. Of  course,  allowance  will  have  to  be  made  for  those  cases  of 
the  manic — depressive  group,  with  a  marked  inherited  instability — 
and  where  the  psychic  disturbance  is  one  of  the  very  early  symptoms 
of  pellagra.  It  is  of  interest  to  note,  in  contrast  to  the  frequency  of 
pellagra  in  the  colored  female  in  Georgia,  the  negro  male  appears 
seldom  to  suffer  from  the  disease. 

However,  so  far  as  can  be  ascertained,  there  has  never  been  a 
case  of  pellagra  to  develop  among  the  nurses,  white  or  colored,  while 
employed  as  such  in  the  Georgia  State  Sanitarium. 

Third. — Certain  pseudo-pellagrous  states  arising  from  a  general 
toxaemia,  resulting  from  a  mixed  infection  of  pathogenic  bacteria, 
is  only  mentioned  because  of  the  many  clinical  conditions  which 
seem  to  portray  a  picture  of  this  character.  More  notable  is 
this  condition  among  the  insane,  and  especially,  such  psychoses  as 


143 

come  under  the  dementia  prsecox  type.  These  patients  will  sit  in 
katatonic  stupor  with  the  buccal  cavity  full  of  offensive  saliva.  They 
will  gradually  develop  a  stomatitis  with  a  chain  of  nervous  symp- 
toms and  morbid  anatomy  almost  identical  with  classic  pellagra. 
From  my  observation,  the  digestive  disturbance  with  diarrhoea 
usually  precedes  the  local  epidermal  changes,  in  these  cases,  and  the 
picture,  as  a  clinical  unity,  points  primarily  to  a  toxic  infection 
arising  either  from  a  neglected  oral  hygiene  or  a  poisoned  saliva. 

Dr.  John  A.  Fordyce,  of  New  York,  in  a  very  excellent  paper,  has 
shown  the  very  close  relationship  of  mucous  membrane  affections  to 
certain  diseases  of  the  skin.  Many  pseudo-pellagrous  states  are  quite 
significant  in  this  connection,  as  good  observers  have  shown  that 
catarrhal  inflammations  of  the  skin  may  interchange  with  those  of 
the  mucous  membranes, — the  one  being  active,  while  the  other  may 
be  in  abeyance.  Pertinent  is  the  theory  in  this  connection  that  certain 
nervous  diseases  may  have  their  morbid  expression  in  cutaneous 
manifestations. 

The  physiologists  tell  us  that  the  nervous  system,  the  epidermis 
and  the  epidermic  tissues,  with  the  mucous  membrane  of  the  mouth 
and  rectum,  all  have  their  histogenesis  in  the  same  embryonic  mem- 
brane, that  is,  the  epiblast. 

Now,  admitting  the  fact  that  the  pathognom.onic  symptoms  of  pel- 
lagra are  shown  in  a  triad  of  morbid  conditions  visible  through  either 
one  or  all  of  these  systems — are  we  in  a  position  to  deny  that  a 
general  toxaemia,  beginning  in  the  oral  cavity,  might  not  be  con- 
founded with  many  of  the  pseudo-pellagrous  states  now  existing 
throughout  the  country.  Certainly  with  the  physicians  in  Georgia, 
there  is  a  disposition  to  assign  to  the  pseudo-pellagrous  group  such 
morbid  pictures  as  sustain  a  cliliical  relationship  to  chronic  syphilis 
and  tuberculosis.  Especially  is  this  true  where  syphilis  and  tubercu- 
losis are  associated  with  insanity,  and  the  clinical  picture  is  one  of 
a  wasting  disease  with  such  nervous ,  symptoms  as  might  be  present 
in  pellagra. 

Take  the  novice  and  carry  him  through  the  colored  female  depart- 
ment of  the  Georgia  State  Sanitarium,  and  you  will  hear  the  spon- 
taneous expression  from  him, — Syphilis !  Tuberculosis !  in  reference 
to  many  of  the  so-called  pellagra  cases. 


144 

DIAGNOSIS— PSYCHIC  PHENOMENA. 

I  trust,  for  lack  of  time,  I  may  be  pardoned  for  embracing  'under 
this  general  heading  the  remaining  phases  of  pellagra  which  I  desire 
to  consider,  though  some  do  not  properly  belong  here. 

The  disease,  as  a  clinical  problem,  has  attracted  attention  for  many 
years  in  the  Georgia  State  Sanitarium.  It  was  construed  as  a  morbid 
attribute  to  insanity,  with  certain  nervous  and  physical  complications, 
in  which  syphilis  and  tuberculosis  played  an  important  role  as  etio- 
logical factors. 

As  far  back  as  1898,  the  records  of  the  pathological  department 
of  the  Georgia  State  Hospital  will  show  that  such  colloquial  and 
incorrect  nomenclature  as  foot  and  mouth  disease,  marasmus,  malig- 
nant stomatitis,  cochin  china  diarrhooea,  tubercular  enteritis,  and 
solar  dermatitis  were  given  to  the  disease,  and  these  phrases  are  sug- 
gestive of  such  symptoms  as  may  have  predominated  in  the  clinical 
picture  from  time  to  time.  Finally,  all  of  this  doubt  and  confusion 
as  regards  the  malady  was  concluded,  to  a  degree,  in  the  happy  relief 
afforded  by  Tropical  Aptha  or  Sprue,  which  became  prominently 
recognized  in  Georgia  through  the  splendid  reports  of  this  disease  by 
Dr.  H.  F.  Harris,  of  Atlanta.  With  the  advent  of  sprue,  however, 
there  arose  a  narrow  but  perplexing  chasm  in  the  differential  diag- 
nosis of  the  two  diseases ;  the  differential  points  are  still  treacherous, 
and  I  fear  their  significance  lies  more  in  the  hypothesis  of  theory 
than  the  practical  arts  of  medicinal  diagnosis. 

I  shall  only  record  my  personal  observations  as  to  the  pathogenesis, 
as  the  conclusions  of  the  very  best  men  in  this  country  and  abroad  are 
practically  in  accord  as  to  the  morbid  changes.  As  to  whether  the  dis- 
ease possesses  an  incubation  period,  the  author  is  unable  to  say.  In  all 
probability  it  does,  yet,  the  writer  has  never  seen  such  statement  from 
reliable  authority.    The  peculiar  stomatitis,  with  or  without  aphthous 
deposits ;  pain  in  the  back ;  a  red-brownish  pigmentation,  sometimes 
of  a  fungoid  character, — about  the  face,  neck,  chest,  inner  surfaces 
of  thighs,  vulva  and  upper  folds  of  buttocks,  are,  no  doubt,  familiar  ^ 
to  you  all.     The  characteristic  epidermal  changes  about  the  elbowsj 
and  the  dorsal  surfaces  of  the  hands  and  feet,  varying  from  a  mere! 
discoloration  of  the  skin  to  fissures  and  superficial  necroses  are  tool 
common  to  dwell  on  here.     I  wish  to  say,  however,  that  oftentimesj 
the  epidermal  changes  involve  the  palms  of  the  hands,  soles  of  feet] 
and,  indeed,  quite  a  number  of  instances  have  come  under  my  obser- 
vation in  which  the  flexor  regions  of  the  wrists  have  also  shared] 


145 

in  the  necrosis.  This  is  a  rather  infrequent  condition  and  has  not 
been  observed  by  some  writers  on  the  subject.  The  enlargement  of 
the  glands ;  the  low  haemoglobin  percentage ;  in  some  cases  nucleated 
red  cells  and  an  occasional  leukocytosis.  Ulcers  in  the  caecum,  often 
tubercular  in  character,  are  frequently  associated  with  pellagra.  So 
far  as  I  have  been  able  to  learn,  there  has  been  nothing  of  clinical 
significance  in  the  spinal  fluid.  Brown  and  Low  observed  no 
increase  of  cells  in  the  case  examined  by  them.  The  re-action  of  the 
moist  epidermal  changes  are  as  a  general  thing  slightly  alkaline. 
When  there  is  diarrhoea,  the  stools  may  be  from  three  to  fifteen 
a  day,  either  slimy  pea-soup  or  light  brown  in  color;  sometimes 
frothy,  and  of  alkaline  or  acid  re-action.  Dysentery  may  precede  any 
definite  pellagrous  symptoms  for  weeks  or  months.  Coarse  tremor, 
with  disturbances  of  co-ordination,  is  often  present,  depending 
apparently  upon  the  degree  of  infection. 

The  cycle  of  the  skin  lesions  holds  no  definite  place,  as  to  develop- 
ment and  recession,  in  the  morbid  picture.  The  rash,  while  present 
more  often  in  summer,  does  appear  in  winter,  and  I  have  seen  bullae 
develop  on  the  hands,  fingers,  and  thighs,  of  white  females,  from 
twenty-four  hours  to  two  days  before  death.  Their  occurrence  is 
indicative  of  profound  infection,  and  is  usually  associated  with  mori- 
bund states.  The  temperature  curve  is  void  of  typical  features,  more 
often  it  is  normal,  or  may  be  sub-normal  or  go  as  high  as  105 
degrees.  The  pulse  appears  to  bear  some  relation  to  the  degree  of 
intoxication  and  extent  of  mental  involvement.  In  my  experience, 
there  has  been  a  striking  absence  of  vaso-motor  influence  in  relation 
to  the  skin  and  its  eliminative  function ;  the  surface,  even  in  the 
delirious  forms,  being  dry  and  scaly.  I  have  observed  multiple 
abscess  in  two  cases.  The  appetite  is  usually  poor,  in  some  cases 
ravenous.  Vomiting  is  infrequent.  The  urine  has  shown  nothing 
of  clinical  value.  The  musculature  in  mild  cases  presents  the  picture 
of  fatigue  toxaemia.  The  reflexes  may  be  exaggerated,  diminished 
or  absent.  Sensation  among  the  insane  is  quite  variable, — it  is  hard 
to  determine  whether  there  is  any  true  alteration  or  not.  In  cases 
where  the  spinal-cord  seemed  to  be  involved,  I  have  seen  marked 
intention  tremor  simulating  pseudo-convulsive  attacks. 

In  considering  the  neuro-psychic  phase  of  pellagra,  it  will  be 
expedient  to  study,  first,  the  two  conditions  together,  without  atten- 
tion to  their  strict  division  into  separate  clinical  entities.  Indeed,  I 
might  say,  seldom  do  we  have  in  Georgia  an  organic  disease  of  the 
nervous  system,  of  pellagrous  origin,  without  invasion  of  the  psychic 
10— P.  c. 


146 

realm.  On  the  contrary,  so  intimately  associated  are  the  two  maladies 
in  many  of  their  clinical  aspects,  that  we  are  often  perplexed  to  know 
which,  if  either,  merits  the  place  of  priority  in  occurrence.  An  illus- 
tration will  more  adequately  explain  the  confusion  which  has  arisen 
in  the  author's  mind  as  to  whether  a  primary  neurosis,  of  a  non-pella- 
grous  etiology,  might  exhibit  a  secondary  symptom  complex,  simulat- 
ing the  pellagrous  syndrome.  Take,  for  example,  amyotrophic  lateral 
sclerosis  complicated  with  insanity — the  two  diseases  may  progress 
with  the  preponderance  of  symptoms  favoring  a  spinal  cord  lesion 
as  the  primary  site  of  invasion.  The  mental  states  may  var}'  from 
mild  confusion  to  complete  delirium;  the  reflexes  may  be  exagger- 
ated with  a  variable  Babinski  and  Gordon  paradox;  the  patient 
gradually  develops  a  sore  mouth,  with  alternating  diarrhoea  and 
constipation;  later  the  skin  lesions  appear  with  variable  intensity. 
Have  we  pellagra  with  amyothrophic  lateral  sclerosis  and  insanity 
as  complications,  or  have  we  insanity  and  organic  cord  disease  with 
a  pellagrous  complex?  The  cord  lesions  are  usually  confined  to  the 
lateral  columns ;  the  posterior  or  sensory  may  also  be  invaded,  espe- 
cially in  the  tabetic  forms.  The  cortical  cell  changes,  in  the  insane, 
are  probably  dependent  to  some  degree  upon  the  type  of  psychosis 
and  its  duration. 

In  our  American  nomenclature,  we  have  no  distinctive  classifica- 
tion for  pellagrous  insanity;  the  different  psychic  alterations  falling 
under  such  category  as  the  symptom  complex  may  indicate; — scien- 
tifically speaking,  all  psychoses  of  pellagrous  etiology — excluding 
organic  diseases  of  the  brain  and  nervous  system,  should  fall  prin- 
cipally under  the  intoxication  or  infective  exhaustive  group.  How- 
ever, for  the  sake  of  clearness,  I  have  divided  the  classification,  gen- 
erally speaking,  into  four  headings.  The  conclusions,  as  regard  the 
separate  mental  reaction  states,  having  been  obtained  by  carefully 
isolating  such  symptom  groups  as  are  more  or  less  peculiar  and 
constant  in  the  different  insanity  phases. 

First. — 

The  cases  showing  a  profound  intoxication,  with  early  deli- 
rium, high  temperature  range,  with  symptoms  pointing  to  acute 
organic  changes  in  the  cord  or  brain. 

Controlling  phase :  Complete  or  incomplete  psycho-motor  sus- 
pension. 

Classification  :     Acute  Intoxication  Psychosis. 


147 

Second, — 

Those  cases  of  an  apparent  mild  infection  with  some  mental 
anxiety,  apprehensive  hallucinosis,  gradually  increasing  mental 
confusion, — finally  delirium, — temperature  subnormal  or  slightly 
elevated, — this  type  usually  covering  six  weeks  to  two  months 
or  more,  ending  in  a  slow  but  progressive  exhaustion. 
Controlling  phase :  Psycho-motor  Retardation — Excitation  (active, 
passive). 

Classification  :    Infective  Exhaustive  Psychosis. 
Third.— 

Those  cases  showing  symptoms  of  mild  melancholia,  chronic 
in    character,    with    remissions    and    exacerbations,    impending 
fear,  suicidal  tendency,  due  more  to  apprehension  than  self- 
reproach  ;  temporary  recovery. 
Controlling     phase:       Psycho-motor     Retardation     (inconstant, 
passive). 

Classification:    Symptomatic  Melancholia. 
Fourth. — 

Those  cases  of  mixed  type  showing  at  times  symptoms  of 
depression,  exaltation,  confusion,  impulsive  acts,  apprehensive 
hallucinosis,  exhaustion,  slow  mental  reduction. — including  the 
Dementia  Praecox  Class. 
Controlling     phase:        Psycho-motor      Retardation — Excitation. 
(Active,  passive,  negative). 
Classification :     Manic-depressive — allied  states. 

REFERENCES. 

1.  Public  Health  and  Marine  Hospital  Service  Report,  1909. 

2.  State  Board  of  Health,  Georgia  Report,  1908. 

3.  Journal  Record  Medicine  (Atlanta,  1909). 

4.  Clinical  Features  of  So-called  Pellagra  (N.  P.  Walker,  Georgia). 
B.  New  York  Medical  Journal    (March,   1909). 

«.  Edinburg  Medical  Journal   (Sept.,  1909). 

7.  Insanity  and  Tuberculosis  in  Southern  Negro  Since  1860   (T.  O.  Powell, 
Georgia). 

8.  Report  Georgia  State  Sanitarium   (1897  to  1909). 


148 
DISCUSSION  ON  THE  PAPER  OF  DR.  MOBLEY 

Dr.  W.  H.  Dial_,  Laurens,  South  Carolina :  I  would  like  to  ask 
those  gentlemen  familiar  with  pellagra  whether  or  not  it  is  necessary 
to  have  a  dermititis  in  order  to  make  a  diagnosis  of  this  disease.  Last 
evening  a  gentleman  from  North  Carolina,  who  mentioned  a  case  in 
which  there  was  stomatitis  and  other  symptoms  of  the  disease,  said 
he  had  made  a  diagnosis  of  pellagra  without  the  skin  manifestations. 
What  we  want  to  know  now  is  whether  dermatitis  is  necessary  as  a 
symptom  in  pellagra.  I  would  like  to  ask  Dr.  Babcock  or  any  other 
member  of  the  conference  to  answer  this  question. 

/ 

Dr.  J.  W.  Babcock,  Columbia,  South  Carolina :  With  your  per- 
mission,. Mr.  Chairman,  I  will  state  what  little  I  know  about  the 
subject,  and  repeat  what  was  brought  up  in  the  conference  last  year, 
namely,  that  students  in  the  London  School  of  Tropical  Medicine 
are  taught  that  they  must  make  a  diagnosis  of  pellagra  regardless 
of  the  dermatitis ;  that  they  must  make  a  diagnosis  of  pellagra  with- 
out waiting  for  the  skin  manifestations  to  develop.  Then,  there  are 
those  cases  which  the  Italians  emphasize  as  of  the  greatest 
importance,  namely,  those  which  have  an  obstinate  diarrhoea,  with 
marked  mental  symptoms,  and  exaggerated  knee  jerks.  In  other 
words,  to  give  a  picture  of  pellagra  without  any  skin  manifestations 
at  all,  so  that  recognizing  that  we  are  all  beginners  in  the  study  of 
this  great  disease,  I  think  it  is  up  to  the  general  practitioner  to 
formulate  for  those  who  only  see  this  condition  in  the  advanced 
stage  to  emphasize  for  us  the  particular  symptoms  which  will  enable 
us  to  make  an  early  diagnosis  regardless  of  the  skin  manifestations, 
because  it  is  in  that  stage  when,  if  we  are  to  help  the  patient,  we 
must  make  a  diagnosis.  When  the  disease  reaches  the  stage  of 
mental  involvement,  when  it  reaches  the  asylum  condition,  we  have 
all  the  evidences  of  an  overwhelming  lethal  tendency.  I  do  not 
know  whether  I  have  made  my  remarks  clear  or  not. 

I 
Dr.  W.  B.  Young,  Rock  Hill,  South  Carolina:  I  have  a  case  I 
would  like  to  report.  The  patient  is  about  55  years  of  age,  a 
farmer  by  occupation,  who  has  a  water  mill  and  grinds  most  of  the 
meal  that  he  uses,  and  he  has  certain  nervous  symptoms  which  I  do 
not  understand.  He  did  not  have  a  dermatitis  when  I  first  saw 
him.  He  had  increased  knee  jerks,  stomatitis,  but  has  never  had 
diarrhoea.     On  the  contrary,  he  was  the  subject  of  obstinate  Con- 


149 

stipation  instead  of  diarrhcea.  In  working  about  the  little  store  near 
his  mill  he  would  pick  up  an  article  and  be  unable  to  put  it  down,  so 
that  it  became  necessary  for  somebody  to  take  it  from  his  hand. 
Again,  he  would  start  to  walk  in  one  direction  and  go  in  the  oppo- 
site direction.  In  attempting  to  sit  in  one  chair  in  the  room  he 
would  get  into  another. 

Mental  symptoms  came  on  after  the  dermatitis  manifested  itself, 
and  then  I  made  a  diagnosis  of  pellagra.  Since  the  dermatitis  and 
constipation  have  become  more  obstinate,  the  patient  has  great 
difficulty  in  moving  his  bowels.  This  is  particularly  the  case  when 
the  dermatitis  is  most  severe.  In  the  spring  the  dermatitis  appeared, 
and  this  fall  it  appeared  again  at  both  times  when  constipation  had 
been  very  obstinate. 

Dr.  B.  R.  Tucker^  Richmond,  Virginia:  In  regard  to  those 
cases  of  pellagra  that  have  occurred  and  are  occurring  outside  of 
institutions,  in  some  of  them  the  mental  changes  have  come  on  early, 
while  in  others  they  have  appeared  late.  Is  it  true  that  the  cases 
of  dementia  which  have  developed  pellagra  have  exacerbations  of 
their  mental  symptoms  at  the  onset  of  the  disease?  I  have  the  his- 
tories of  nine  cases  and  in  eight  of  them  excessive  crying  was  noted 
as  a  symptom,  showing  an  emotional  state.  I  would  like  to  ask 
whether  any  other  members  of  the  conference  have  observed  this 
symptom  ? 


ISO 


COMPLEMENT  FIXATION  WITH  LECITHIN  AS  ANTI- 
GEN IN  PELLAGRA— FURTHER  OBSERVATIONS 

C.  C.  BASSj  M.  D. 

NEW    OBLEANS. 

In  a  preliminary  note  published  in  the  Journal  of  the  American 
Medical  Association,  October  9,  1909,  I  reported  a  positive  comple- 
ment fixation  reaction  with  lecithin  as  antigen  in  six  consecutive 
cases  of  pellagra.  One  of  these  has  since  been  found  to  have  had 
syphilis  and  would  probably  have  given  a  positive  reaction  from  this 
cause.  Another  one  of  the  tests  was  made  on  blood  taken  at  autopsy 
twenty- four  hours  after  death,  and  is  therefore  not  to  be  credited  fully. 
There  remained,  however,  four  cases  that  gave  a  positive  reaction 
without  any  apparent  cause  except  the  presence  of  pellagra.  Since 
that  publication  I  have  tested  the  blood  of  ten  other  cases  of  pellagra 
for  this  reaction,  and  wish  to  report  them  here.  In  these  ten  cases, 
six  were  positive  and  four  were  negative.  Of  the  six  positive  cases 
one  was  known  to  have  had  syphilis  and  would  probably  have  given 
a  positive  reaction  without  the  presence  of  pellagra.  In  the  tabula- 
tion below  it  will  be  convenient  to  include  the  former  six  cases. 


Case 
No. 


Type   of   Disease. 


Reaction. 


5 
6 

7 

8 

11 

12 
13 
14 

18 
20 
21 
22 


23 
24 
25 


Chronic  case,  4  years'  duration  ;  severe  acute  attack ;  in- 
sanity and   death 

Mild  acute  case  ;  first  year,  improved 

Severe  acute  case  ;  death,  had  had  syphilis 

Severe  acute  case  ;  death,  blood  taken  24  hours  after  death 

Mild   chronic  case,   severe  skin   lesions;   improved 

Moderately  severe  case  ;  also  had  T.  B.,  which  contributed 
to  her  death 

Severe  first  attack  ;  death  in  one  month 

Severe  case  ;  diarrhoea  1 1-2  years  ;  erythema  10  days .... 

Severe  case  ;  diarrhoea  and  vaginitis  two  years  ;  erythema 
two  months  ;  had  had  syphilis 

Mild    chronic   case  ;    improving 

Very   severe   case ;   death 

Mild  case ;   first    ( ?)    year 

Moderately  severe,  acute  attack :  three  or  four  summers 
erythema ;  three  months'  emaciation ;  diarrhoea  and 
indigestion    27    years 

Moderately  severe  case  first  summer ;  estivo-autumnal 
Plasmodia  in  blood  ;  great  anemia 

Three  years'  diarrhoea ;  severe  mental  symptoms  now ; 
erythema  pretty  well  cleared  up 

Severe  case,  diagnosed  by  Dr.  Lavinder 


Positive 
Positive 
Positive 
Positive 
Positive 

Positive 
Negative 
Negative 

Positive 
Positive 
Positive 
Positive 


Positive 

Positive 

Negative 
Negative 


Technic. — It  will  not  be  necessary  to  describe  the  technic  in  detail, 
as  it  is  the  Wasserman  serum  reaction  for  syphilis,  with  slight  modi- 
fications to  suit  my  own  convenience,  and  substituting  as  antigen 
lecithin  for  syphilitic  liver  extract.    The  hemolytic  system  used  was 


151 

sheep  blood  corpuscles,  guinea  pig  complement  and  sensitive  rabbit 
serum  amboceptor. 

The  hemolytic  unit  used  in  all  tests  was  1/20  c.  c.  of  sheep  cor- 
puscles. The  lecithin  solution  used  for  antigen  is  a  0.3  per  cent, 
solution  in  equal  parts  absolute  alcohol  and  salt  solution.  One-tenth 
c.  c.  of  this  per  hemolytic  unit  was  quantity  used.  One-tenth  c.  c. 
patient's  serum  per  hemolytic  unit  must  bind  the  unit  of  complement 
or  the  test  is  considered  negative.  All  except  five  of  the  tests  here 
tabulated  were  made  with  inactivated  serum.  All  the  tests  were 
controlled  by  running  through  at  the  same  time  a  normal  negative 
serum  and  also  a  reacting  syphilis  blood  exactly  as  is  usually  done 
in  making  Wasserman's  reaction  for  syphilis. 

An  analysis  of  the  sixteen  cases  shows  that  two  have  had  syphilis, 
one  was  done  on  old  autopsy  blood,  and  another  had  estivo-autumnal 
Plasmodia  in  the  blood  when  the  test  was  made.  Excluding  these 
possible  sources  of  error,  we  still  have  eight  out  of  twelve  cases 
giving  a  positive  reaction.  Of  these  eight  positive  cases  seven  were 
of  the  mild  or  chronic  type  and  only  one  was  of  the  severe  acute 
type.  Of  the  four  negative  cases  all  had  severe  acute  attacks  and 
two  had  their  first  attacks.  Two  of  these  are  alive  but  do  not 
promise  to  recover  from  the  present  attack.  The  reaction  seems 
more  likely  to  be  present  in  chronic  mild  cases  and  those  showing 
some  resistance  to  the  disease  which  is  in  keeping  with  the  fact  that 
the  complement  fixation  reaction  is  due  to  the  presence  of  antibodies 
for  lipoid  substances. 

The  observations  here  reported  are  on  far  too  few  cases  to  permit 
final  conclusion.  They  should  be  confirmed  by  study  of  a  much  larger 
number  of  cases  by  competent  observers. 

The  complement  fixation  reaction  with  lipoid  substances  as  antigen 
has  been  found  in  syphilis  especially,  but  also  in  trypanosomiasis, 
sleeping  sickness,  kala-azar,  certain  cases  of  malaria,  a  few  cases  of 
scarlet  fever,  and  probably  other  diseases.  All  of  these,  except  pos- 
sibly scarlet  fever,  are  protozoan  diseases.  The  reaction  has  not  been 
found  in  bacterial  diseases  except  in  rare  instances. 

At  the  suggestion  of  Dr.  Dock  the  strength  of  the  reaction  was 
determined  in  three  positive  cases.  One-tenth  c.  c.  serum  in  one  case 
fixed  two  units  of  complement ;  another  fixed  four  units ;  and  one,  a 
case  of  two  years'  duration,  fixed  twenty  units  of  complement. 

I  am  indebted  to  the  Charity  Hospital  staff  and  to  many  physicians 
of  New  Orleans  and  vicinity  for  courtesies  shown. 

741  Carondelet  Street. 


152 


THE  WASSERMANN  REACTION  (NOGUCHI  MODIFICA- 
TION) IN  PELLAGRA— REPORT  OF  THIRTY  CASES 

Report  of  Thirty  Cases. 
dr.  howard  fox 

NEW    TOEK    CITY. 

In  a  recent  communication  (Jour.  A.  M.  A.,  1909,  p.  1187),  Dr. 
C.  C.  Bass,  of  Tulane  University,  reports  that  he  has  obtained  six 
positive  Wasserman  reactions  in  six  cases  of  pellagra,  using  lecithin 
as  antigen.  He  suggests  that  these  results  if  confirmed  may  "tend 
to  strengthen  the  idea  that  the  disease  is  of  protozoan  origin."  He 
further  states  that  it  would  add  another  disease  to  be  considered  in 
interpreting  a  positive  Wassermann  reaction.  It  is  with  the  purpose 
of  continuing  these  researches  that  the  writer  has  come  to  the  State 
where  so  many  cases  of  pellagra  have  been  recognized.  Owing  to 
the  kindness  of  Dr.  J.  W.  Babcock  and  Surgeon-General  Wyman, 
free  access  to  a  most  unusual  material  has  been  obtained. 

Thirty  cases  of  pellagra  have  been  tested  by  the  Noguchi  modi- 
cation  of  the  Wessermann  reaction.  The  writer  would  have  pre- 
ferred, as  has  been  his  custom,  to  have  performed  both  the  regular 
Wassermann  and  Noguchi  tests  simultaneously.  Owing  to  the 
limited  amount  of  time  available,  it  was  only  possible  to  employ  the 
more  convenient  modification  of  Noguchi.  The  writer  feels  con- 
vinced, however,  that  the  Noguchi  test  is  fully  as  accurate  as  the 
original  method  of  Wassermann. 

The  cases  examined  included  eight  white  and  twenty  colored 
women,  one  white  man  and  one  colored  boy.  All  of  the  patients  were 
from  South  Carolina,  and  with  the  exception  of  Case  i,  were 
inmates  of  the  State  Hospital  for  the  Insane.  All  of  the  cases,  with 
perhaps  one  exception,  have  shown  unmistakable  symptoms  of  pella- 
gra, though  at  the  time  of  examination  some  did  not  present  very 
active  symptoms  of  the  disease.  The  cases  which  were  chosen  for 
examination  were  those  which  apparently  showed  no  evidence  of 
syphilis.  To  have  excluded  syphilis  from  the  patient's  history  would 
have  been  difficult  or  impossible  from  the  nature  of  the  cases. 

The  technique  was  that'  described  by  Noguchi  and  by  the  writer 
in  previous  communications  (N.  Y.  Med.  Record,  March  13,  '09, 
and  .Jour.   Cutaneous   Diseases,   Aug.,   '09).     The  materials  used 


153 

included  0.04  c.  c.  of  fresh  guinea  pig  serum,  a  weak  suspension 
of  human  corpuscles  (preferably  washed)  in  the  proportion  of  one 
drop  to  4  c.  c.  of  physiological  salt  solution,  one  capillary  drop  of 
patient's  serum  (active)  and  the  antigen  and  amboceptor  in  paper 
form.  The  tubes  were  incubated  for  one-half  hour  for  the  first  and 
two  hours  for  the  second  period,  after  which  the  results  were  read. 
Two  different  antigens  were  used  in  testing  every  case.  One  of 
these  consisted  of  an  extract  of  syphilitic  liver;  the  other  (especially 
prepared  by  Dr.  Noguchi  for  the  present  investigation)  was  a  com- 
posite extract  of  syphilitic  liver  and  normal  hearts  and  kidneys. 
Both  had  previously  been  tested  by  Dr.  Noguchi  and  found  to  be 
entirely  satisfactory. 

In  performing  the  reaction,  a  known  negative  serum  and  one  or 
more  known  positive  sera  were  always  used  for  comparison.  The 
positive  sera  included  five  cases  of  syphilis  and  two  of  leprosy  which 
the  writer  had  previously  tested  and  found  to  be  strongly  positive. 
The  entire  series  of  thirty  cases  was  tested  four  times.  With  the 
exception  of  one  case,  no  strongly  marked  positive  reactions  were 
obtained.  In  this  case  it  was  later  found  that  a  previous  syphilitic 
infection  was  quite  probable.  In  two  other  cases  there  was  a  posi- 
tive reaction  of  moderate  intensity  and  in  five  cases  the  reaction 
was  only  weakly  positive.  Even  in  the  cases  giving  a  moderate 
positive  reaction  the  inhibition  of  haemolysis  was  far  from  being 
complete  and  was  very  easy  to  distinguish  from  the  marked  reaction 
given  by  the  syphilitic  and  leprous  sera. 

While  positive  reactions  are  at  times  given  in  apparently  non- 
syphilitic  cases  there  appears  to-be  only  one  disease,  namely,  leprosy, 
in  which  a  strong  positive  reaction  is  a  frequent  occurrence.  In  an 
examination  of  fifteen  cases  of  leprosy  during  the  past  few  months 
in  New  York  the  writer  found  twelve  positive  reactions,  many  of 
them  being  very  intense.  Somewhat  similar  results  have  previously 
been  obtained  by  other  observers.  The  writer  feels  confident  that 
pellagra  will  not  prove  to  be  a  disease  in  which  a  positive  Wasser- 
mann  reaction  will  be  frequently  found.  If  such  a  sensitive  test 
as  that  of  Noguchi  (and  the  objection  is  sometimes  made  that  it  is 
too  sensitive)  fails  to  show  many  positive  reactions,  it  does  not  seem 
probable  that  they  will  be  obtained  by  the  regular  Wassermann 
method. 

CASES. 

Case  I. — G.  S.,  boy,  colored,  12  years  old — symptoms  of  pellagra 
first  noticed  five  years  ago.    At  present  there  is  an  extensive  erup- 


154 

tion  of  face,  neck  and  back  of  hands,  wrists,  elbows  and  legs.  There 
is  constant  salivation,  distressing  thirst,  red  tongue,  severe  uncon- 
trollable diarrhoea,  spastic  gait,  greatly  increased  reflexes,  unequal 
pupils.  There  are  frequent  tonic,  muscular  spasms  drawing  the 
body  to  the  left  side.  Patient  is  greatly  emaciated.  Mental  condi- 
tion is  not  affected.     Reaction :  Weakly  positive. 

Case  2. — H.  M.,  woman,  colored,  about  50  years  old — manic 
depressive  insanity.  First  attack  of  pellagra  four  years  ago.  Fairly 
well  till  one  month  ago,  when  symptoms  recurred.  At  present  erup- 
tion on  face  and  hands.  Diarrhoea.  Knee  jerk  absent.  Reaction: 
Negative. 

Case  3. — F.  W.,  woman,  colored,  about  28  years  old.  Manic 
depressive  insanity  with  pellagra.  Symptoms  of  pellagra  first 
noticed  three  weeks  ago.  At  present  red  tongue,  diarrhoea,  erythema 
of  backs  of  hands.     Knee  jerk  increased.    Reaction : 'Negative. 

Case  4. — H.  J.,  woman,  colored,  about  28  years  old — manic 
depressive  insanity  with  acute  pellagra.  First  symptoms  of  pellagra 
noticed  ten  months  ago.  At  present  characteristic  eruption  of  hands, 
feet  and  neck — salivation.     Reaction  :  Negative. 

Case  5. — M.  H.,  woman,  about  45  years  old — epilepsy.  First 
symptoms  of  pellagra  developed  six  weeks  ago.  At  present  marked 
characteristic  eruption  of  hands  and  neck,  diarrhoea,  exaggerated 
knee  jerk.    Reaction:  Moderately  positive. 

Case  6. — M.  L.,  woman,  colored,  about  50  years  old — manic 
depressive  insanity  with  pellagra.  First  symptoms  of  pellagra 
noticed  six  weeks  ago.  Characteristic  eruption  of  hands  and  neck, 
diarrhoea.     Knee  jerk  abolished.    Reaction  :  Negative. 

Case  7. — M.  H.,  woman,  colored,  about  35  years  old — manic 
depressive  insanity  with  pellagra.  First  symptoms  of  pellagra 
noticed  three  weeks  ago.  At  present  characteristic  eruption  of  hands 
and  neck,  diarrhoea,  red  tongue.  Knee  jerk  abolished.  Reaction: 
Moderately  positive. 

Case  8. — L.  L.,  woman,  colored,  18  years  old — pellagrous  insanity. 
Admitted  with  symptoms  of  pellagra  three  months  ago.  At  present 
eruption  of  hands,  elbows  and  legs.  Has  attacks  of  rigidity  of 
dorsal  muscles — tongue  rough,  with  elevated  papillae — diarrhoea. 
Knee  jerk  much  exaggerated.    Reaction:  Negative. 

Case  9. — E.  P.,  woman,  colored,  about  25  years  old — paresis  with 
pellagra.  First  symptoms  of  pellagra  six  weeks  ago — tongue  slightly 
checkerboard.     Knee  jerk  abolished.     Reaction :  Weakly  positive. 


155 

Case  lo. — R.  A,,  woman,  colored,  43  years  old — pellagrous 
insanity  suggesting  alliance  with  paresis.  Patient  admitted  one 
month  ago  with  characteristic  eruption  on  hands  and  feet — diarrhoea. 
Tongue  fissured  (checkerboard).  Knee  jerk  abolished.  Reaction: 
Negative. 

Case  II. — ^J.  B.,  woman,  colored,  about  60  years  old — pellagrous 
insanity.  First  symptoms  of  pellagra  one  year  ago.  At  present 
nearly  well.  Exaggerated  knee  jerk.  Bronzing  of  exposed  surfaces. 
Reaction:  Negative. 

Case  12. — S.  K.,  woman,  colored,  about  25  years  old — pellagrous 
insanity.  Admitted  to  hospital  eight  months  ago.  Hands  bronzed — 
marked  salivation.    Knee  jerk  abolished.    Reaction:  Negative. 

Case  13. — M.  W.,  woman,  colored,  about  30  years  old — manic 
depressive  insanity  with  pellagra.  First  symptoms  of  pellagra 
noticed  four  months  ago.  Characteristic  eruption  of  hands  and 
neck.    Knee  jerk  controlled.    Reaction  :  Negative. 

Case  14. — C.  M.  B.,  woman,  colored,  about  40  years  old — manic 
depressive  insanity  with  pellagra.  First  symptoms  of  pellagra  noticed 
one  month  ago.  Characteristic  eruption  on  hands  and  neck.  Reflexes 
exaggerated.    Reaction :  negative. 

Case  15. — H.  C,  woman,  colored,  35  years  old — pellagrous  in- 
sanity. Admitted  to  hospital  two  months  ago  with  symptoms  of 
insanity.  Tongue  fissured  and  slimy.  Nails  slightly  clubbed — 
elbows  slightly  pigmented.  Knee  jerks  normal.  Reaction :  Nega- 
tive. 

Case  16. — J.  C,  woman,  colored,  about  45  years  old — pellagrous 
insanity — melancholia  one  year  ago.  Eruption  first  noticed  during 
past  summer.  At  present  typical  eruption  on  hands  and  neck — 
pigmented  tongue.     Knee  jerk  abolished.     Reaction:  Negative. 

Case  17. — J.  T.,  woman,  colored,  about  35  years  old — pellagrous 
insanity.  First  symptoms  noticed  one  year  ago.  At  present  eruption 
on  hands.     Lips  exfoliated.     Knee  jerk  brisk.     Reaction :  Negative. 

Case  18. — L.  M.,  woman,  colored,  28  years  old — pellagrous  in- 
sanity. History  of  attack  one  year  ago.  Present  attack  began  one 
month  ago.  Eruption  on  face,  hands  and  feet.  Severe  diarrhoea — red 
tongue.  Knee  jerk  slightly  exaggerated.  Confined  to  bed.  Reac- 
tion :  Weakly  positive. 

Case  19. — M.  P.,  woman,  colored,  about  50  years  old — clinical 
diagnosis  of  paresis  on  admission  nine  months  ago.  Symptoms  of 
pellagra  first  noticed   two  months   ago.      At  present   eruption  of 


iS6 

hands  and  feet — broad  slimy  tongue.     Some  ptyalism.     Diarrhoea. 
Confined  to  bed  recently.    Reaction  :  Negative. 

Case  20. — T.  W.,  woman,  colored,  about  30  years  old — manic 
depressive  insanity  with  pellagra.  First  symptoms  of  pellagra 
noticed  one  year  ago.  Depression,  diarrhoea,  pigmented  tongue. 
Knee  jerk  abolished.    Reaction  :  Negative. 

Case  21. — D,  H.,  woman,  colored,  30  years  old,  married — pella- 
grous insanity.  History  of  attack  one  year  ago.  At  present  few 
symptoms.    Reflexes  exaggerated.    Reaction :  Negative. 

Case  22. — L.  B.,  woman,  white,  32  years  old,  married — ^pellagrous 
insanity  of  manic  depressive  type.  Has  run  a  typical  course  with 
eruption,  stomatitis  and  diarrhoea.  Duration  of  disease  two  years. 
At  present  mental  instability — erythema  of  back  of  hands.  Reac- 
tion :  Weakly  positive. 

Case  23. — M.  H.,  woman,  white,  28  years  old,  married — pella- 
grous insanity  with  suicidal  tendency.  Has  run  a  typical  course  of 
pellagra  with  predominance  of  mental  symptoms.  Disease  associated 
with  pregnancy.  Duration  less  than  one  year.  At  present  no  erup- 
tion.   Reaction:  Negative. 

Case  24. — M.  O.,  woman,  white,  36  years  old,  single — pellagra 
engrafted  on  hallucinatory  insanity.  Has  run  typical  course  with 
marked  anemia.  Repeated  attacks  of  pellagra  several  times  a  year. 
Duration  of  pellagra  two  years.  At  present  diarrhoea,  anaemia, 
erythema  of  backs  of  hands.    Reaction :  Weakly  positive. 

Case  25. — M.  W.,  woman,  white,  about  50  years  old,  married — 
manic  depressive  insanity  of  long  duration.  Pellagra  has  developed 
within  the  last  year  and  has  run  typical  course.  At  present  marked 
diarrhoea,  eruption,  stomatitis,  depression.     Reaction :  Negative. 

Case  26. — B.  G.,  woman,  white,  35  years  old,  married — pellagrous 
insanity.  Duration  of  disease  four  months.  At  present  marked,  very 
slight  eruption,  anaemia,  diarrhoea.    Reaction :  Negative. 

Case  27. — F.  R.,  woman,  white,  36  years  old,  single — pellagrous 
insanity.  Duration  one  year.  At  present  ansemia,  depression, 
diarrhoea,  eruption.     Patient  emaciated.    Reaction :  Negative. 

Case  28. — L.  B.,  woman,  white,  45  years  old,  single — Moral  imbe- 
cility with  pellagra.  Duration  of  pellagra  two  years.  At  present 
tongue  swollen  and  indented  by  teeth.  Stomatitis,  diarrhoea,  marked 
emaciation — eruption  on  back  of  hands.    Reaction :  Negative. 

Case  29. — M.  B.,  woman,  white,  about  40  years  old,  married — 
pellagrous  insanity.     Duration  of  disease  six  months.     At  present 


157 

ansemia,  diarrhoea,  marked  emaciation — very  slight  eruption  on  back 
of  hands.    Reaction  :  Moderately  positive. 

Case  30. — S.  C.  L.,  man,  white,  about  35  years  old — pellagrous 
insanity.  Duration  of  disease  two  years.  At  present  delusions 
(suicidal),  stomatitis,  uncontrollable  diarrhoea.   Reaction:  Negative. 

The  writer  desires  to  express  his  heartfelt  thanks  to  Dr.  J.  W. 
Babcock,  Superintendent  of  the  State  Hospital  for  the  Insane,  and 
to  Dr.  Walter  Wyman,  Surgeon-General,  U.  S.  Public  Health  and 
Marine-Hospital  Service,  for  permission  to  examine  the  cases.  He 
is  also  indebted  for  laboratory  facilities  to  Dr.  C.  F.  Williams, 
Secretary  of  the  State  Board  of  Health,  and  Dr.  F.  A.  Coward, 
Director  of  the  Laboratory.  For  Case  No.  i  the  writer  wishes  to 
thank  Dr.  J.  J.  Watson. 

CONCLUSIONS. 

1.  Cases  of  pellagra  do  not  often  give  a  positive  Wassermann 
reaction. 

2.  A  positive  reaction,  when  obtained,  is  generally  weak  and  is 
easily  distinguished  from  the  strong  reactions  found  in  syphilis  and 
in  many  cases  of  leprosy. 

3.  The  value  of  the  Wassermann  test  is  not  affected  by  the  find- 
ings in  pellagra. 


158 


TRANSFUSION  IN  PELLAGRA 

H.    P.    COLE,   M.  D.,   AND   OILMAN   J.    WINTHROP,    M.   D. 

MOBILEj    ALA. 

The  existing  uncertainty  as  to  the  etiology  and  as  to  the  toxin  or 
toxins  producing  the  symptoms  of  pellagra,  prohibit,  at  present,  the 
formulating  of  a  scientific  or  rational  therapy.  Any  remedial  or  sur- 
gical measures  employed  must  necessarily  be  based  on  empiricism 
and  experimentation. 

Study  on  the  etiology  of  the  disease,  chiefly  by  Italian  and  German 
workers  and  more  recently  in  this  country,  has  led  to  three  chief 
theories  as  to  the  cause  of  pellagra.  Firstly,  the  maize  or  "zeist" 
theory,  which  holds  that  decomposition  of  the  oils  or  "zein"  of  corn 
produces  the  poisons  causing  pellagra.  Secondly,  the  "verdet"  theory 
of  Lombroso,  which  claims  that  the  growth  of  certain  fungi,  peni- 
cilli  and  aspergilli  on  maize  produces  a  toxin.  The  ingestion  of  this 
toxin  containing  corn  produces  pellagra.  Thirdly,  the  microbic  or 
bacterial  theory,  suggested  by  Tizzoni,  Panichi  and  others,  which 
supposes  that  pellagra  is  due  to  a  specific  bacterium  which  grows  on 
maize  and  elaborates  characteristic  toxins. 

That  maize,  especially  when  exposed  to  moisture  and  heat,  bears  a 
close  causative  relation  to  pellagra  is  rather  generally  conceded. 
Whether  the  toxic  principles  are  developed  in  the  corn  itself  or 
whether  maize  is  pathogenic  only  in  so  far  that  poisons  can  develop 
in  it  by  the  action  of  micro-organisms  is  still  a  matter  of  speculation. 

A  discussion  as  to  the  theories  of  the  etiology  of  pellagra  is  beyond 
the  scope  of  this  paper.  We  shall  confine  ourselves  to  a  consideration 
of  the  theories,  experiments  and  facts  bearing  on  the  nature  and 
action  of  the  toxic  substances  of  pellagra,  no  matter  what  be  their 
origin,  and  suggest  the  possibility  of  combatting  these  toxins  in  vivo 
by  antagonistic  substances  formed  in  the  body  by  natural  or  acquired 
immunity. 

Granting,  as  seems  justifiable,  that  pellagra  is  an  intoxication,  let 
us  consider  the  work  done  as  to  the  biologic  actions  of  the  toxins. 

Tizzoni  (i)  has  shown  that  by  injecting  the  blood  of  a  pellagrous 
patient  into  animals  typical  symptoms  of  the  disease  are  produced. 
This  may  be  explained  by  the  passage  of  toxins  from  the  affected  to 


159 

the  non-affected  animal,  or,  as  Tizzoni  suggests,  to  the  transmission 
of  living  (toxin-bearing?)  bacteria  specific  of  the  disease. 

Lombroso  (2)  claims  to  have  produced  typical  pellagrous  mani- 
festations by  the  administration  of  an  alcoholic  extract  of  impure 
maize  ("pellagrozein"). 

These  experiments  seemingly  prove  the  existence  of  a  toxic  prin- 
ciple capable  of  producing  pellagrous  symptoms,  laying  aside  any 
consideration  as  to  their  chemical,  microbic  or  fungus  origin. 

Admitting,  then,  the  existence  of  specific  toxins,  may  we  not  ration- 
ally consider  the  probability  that  the  body  tissues  form  anti-bodies  or 
anti-toxins  to  combat  their  action?  Much  of  the  late  work  on  sera 
and  toxins  tends  to  answer  this  supposition  in  the  affirmative. 

Babes  (3)  and  other  workers  have  found  in  the  serum  of  pella- 
grins a  substance  antagonistic  to  the  extracts  of  damaged  maize  that 
is  a  specific  anti-toxic  body. 

Giovanni  and  Gatti  (4),  from  their  work  on  pellagrous  serum, 
conclude  that  the  serum  of  pellagrins  has  a  hemolytic  action  much 
above  normal,  demonstrating  the  presence  of  an  anti-body.  They 
further  claim  to  have  demonstrated  precipitative  properties  in  pel- 
lagrous blood. 

D'Ormea  (5),  working  independently,  likewise  concludes  that 
there  is  a  definite  specific  anti-body  developed  in  pellagrins. 

Antonini  and  Marianni  (6)  claim  that  a  definite  immunity  is  de- 
veloped in  cured  cases  of  pellagra  and  that  the  serum  exhibits  a 
definite  anti-toxic  action  against  maize  poisons.  They  have  developed 
an  artificial  immunity  in  rats,  rabbits  and  goats  against  pellagrous 
toxins.  Finally,  they  conclude  that  a  serum  therapy  can  be  instituted 
in  grave  pellagra  cases. 

Accepting  the  statements  of  these  workers,  we  are  led  to  the  fol- 
lowing conclusions : 

(i.)   Pellagra  is  an  intoxication. 

(2.)  The  toxic  principles  of  pellagra  exist  in  the  blood  of  pella- 
grins and  will  produce  pellagrous  symptoms  when  transferred  to 
other  animals. 

(3.)  Pellagrous  serum  exhibits  definite  precipitative,  hemolytic 
and  anti-toxic  properties. 

(4.)  An  artificial  immunity  can  be  produced  in  animals  and  exists 
in  cured  pellagrins. 

Our  work  in  pellagra  was  undertaken  independently  of  any  knowl- 
edge of  the  researches  of  others  as  to  the  existence  of  anti-bodies  in 
pellagra.    Being  interested  in  the  subject  of  transfusion  and  working 


i6o 

on  its  effect  in  shock  and  hemorrhagic  anemia  in  dogs,  we  were  led 
to  try  transfusion  in  pellagra,  at  first,  simply  as  a  relief  for  the  exist- 
ing anemia  in  these  cases.  The  possibility  of  the  existence  of  a 
specific  curative  agent  of  the  nature  of  an  anti-toxin,  performed  in 
cured  cases  and  which  might  be  transfused  with  the  blood,  very  natu- 
rally suggested  itself. 

Through  the  kindness  of  Drs.  McCafferty  and  Tisdale,  of  the  Mt. 
Vernon  Hospital,  we  were  enabled  to  perform  a  transfusion  in  a 
severe  case  of  pellagra,  using  a  cured  case  of  pellagra  as  the  donor. 
As  far  as  we  are  able  to  ascertain,  this  is  the  first  transfusion  per- 
formed in  pellagra.  (7.)  The  results  of  this  first  transfusion  were 
quite  suggestive  and  led  to  further  experimentation.  The  results  and 
conclusions  of  some  nine  cases  of  pellagra  so  far  transfused  are  noted 
in  the  second  part  of  this  paper. 

The  difficulty  of  securing  cured  cases  as  donors  has  forced  us  to 
employ  normal,  healthy  individuals  in  a  number  of  our  transfusions. 
We  have  chosen  these  non-pellagrous  donors  from  among  persons 
living  in  the  same  suroundings,  eating  the  same  food  and  subject  to 
the  same  chances  of  infection  as  the  patients  themselves.  It  is  possi- 
ble that  these  donors  have  developed  a  certain  amount  of  immunity 
and  contain  anti-toxic  bodies  in  their  blood.  Whether  these  anti- 
bodies be  present  or  not,  the  amount  of  blood  furnished  on  trans- 
fusion must,  at  least,  combat  the  existing  anemia  and  stimulate  the 
protective  and  recuperative  activities  of  the  recipient. 

TRANSFUSION  IN  PELLAGRA. 

The  number  of  cases  of  pellagra  so  far  treated  by  serum  injection 
and  direct  transfusion  of  blood  is  too  small  to  permit  of  final  deduc- 
tions as  to  their  therapeutic  value  in  the  disease. 

We  attempt  to  give  below  a  resume  of  the  cases  in  which  serum 
therapy  and  blood  transfusion  have  been  employed.  The  data  for 
this  report  has  been  obtained  from  monographs  and  personal  com- 
munication with  the  various  workers. 

The  curative  value  of  pellagrous  serum  has  been  chiefly  tried  by 
the  Italians.  Antonini  and  Marianni  (8),  using  the  serum  of  recently 
recovered  typhoid  types  of  pellagra,  note  cures  in  several  severe 
cases.  Their  work  was  most  carefully  performed  and  the  potency  of 
the  serum  was  tested  on  animals  before  being  administered  to 
patients.  Lombroso  (ii),  in  a  personal  communication  to  the 
authors  of  this  paper,  comments  on  the  work  of  Antonini  and  Mari- 


i6i 

anni,  and  states  that  the  use  of  serum  is  of  undoubted  value  in  the 
treatment  of  pellagra. 

Dr.  Lavinder,  of  the  Marine  Hospital  and  Public  Health  Service, 
has  employed  serum  in  the  treatment  of  two  cases  of  pellagra.  The 
first  case  received  but  one  injection  of  serum  and  died  within  three 
days  of  an  intercurrent  pneumonia.  The  second  case  received  four 
injections,  and  at  first  seemed  to  improve,  but  this  was  not  continu- 
ous, and  at  the  last  report  the  patient  was  "steadily  losing  ground." 

The  belief  of  the  Italian  workers  in  the  efficiency  of  pellagrous 
serum  will,  we  hope,  lead  to  a  more  extensive  trial  of  this  most  sim- 
ple therapeutic  measure  and  so  furnish  information  as  to  its  true 
value. 

Besides  our  nine  cases  of  direct  blood  transfusion  in  pellagra, 
which  are  given  in  detail  below,  we  wish  to  note  two  other  cases. 
Drs.  Wood  and  Green  (9)  of  Wilmington,  N.  C,  transfused  a  case 
of  three  years'  duration.  This  case,  which  they  state  was  in  a  "hope- 
less condition,"  received  about  six  to  eight  ounces  of  blood  on  trans- 
fusion.   No  apparent  improvement  was  noted  and  the  patient  died. 

The  second  transfusion  to  be  noted  was  performed  by  Drs.  Mc- 
Cafferty  and  Tisdale,  of  the  Mount  Vernon  Hospital,  Mt,  Vernon, 
Ala.  The  patient  was  transfused  from  a  cured  case  of  pellagra  and 
received  approximately  a  pint  of  blood.  Five  days  after  transfusion 
the  skin  lesions  began  to  disappear,  and  in  fourteen  days  the  patient 
was  up  and  walking  about. 

TECHNIC. 

The  following  cases  were  transfused  by  the  canula  method  of  Crile 
or  by  the  suture  method  of  Carrel : 

REPORT  OF  CASES. 

Case  I. — Alice  F.,  age  25;  colored.  Referred  by  Dr.  McCafferty 
and  Dr.  Tisdale,  Mt.  Vernon,  Ala. 

This  patient  has  had  pellagra  for  three  weeks  and  presents,  on 
examination,  the  characteristic  skin  lesions  over  the  hands,  arms, 
face  and  legs.  There  is  a  stomatitis  so  severe  as  to  seriously  inter- 
fere with  nourishment,  incontinence  of  the  bowels,  marked  emaciation 
and  asthenia.     Hemoglobin,  70  per  cent. 

The  patient  is  in  a  moribund  condition. 

Transfusion — August  3,  1908.  The  donor  is  a  well  nourished 
negro  woman  who  recovered  from  a  severe  attack  of  pellagra  one 

11— p.  c. 


l62 

year  ago.     There  was  a  good  transfer  of  blood  for  about  twenty 
minutes. 

August  4,  1908.  Twenty- four  hours  after  the  operation  the 
recipient  shows  marked  signs  of  improvement,  both  in  her  mental 
and  general  condition. 

August  7,  1908.  Four  days  after  the  transfusion  the  patient  has 
improved  markedly  and  is  walking  about  the  ward. 

This  patient  went  on  to  rapid  recovery.  She  has  presented  no 
symptoms  of  the  disease  since  the  operation,  performed  fourteen 
months  ago.  The  recovery  in  this  case  was  so  immediate  and  com- 
plete as  to  be  extremely  suggestive. 

Case  2. — Bessie  B.,  age  22 ;  white.  Referred  by  D.  D.  Armstead, 
Campbell,  Ala. 

For  the  past  four  years  this  patient  has  had  attacks  of  sore  mouth, 
diarrhoea  and  indigestion,  beginning  in  the  spring  and  lasting  about 
six  months  each.  During  these  attacks  the  patient  was  confined  to 
her  bed.  About  fourteen  months  ago  a  red  eruption  appeared  over 
the  backs  of  both  hands  and  wrists ;  this  was  never  painful  and  dis- 
appeared in  a  few  weeks.  The  patient  has  had  sore  mouth  ever  since 
the  eruption  appeared,  and  there  have  been  four  or  five  soft  bowel 
movements  a  day  for  the  past  four  months.  For  several  weeks  there 
have  been  marked  mental  and  nervous  symptoms ;  these  are  increas- 
ing in  severity.  Sensory  symptoms  have  been  present  in  the  feet  and 
head.  In  the  past  eight  days  there  has  appeared  an  erythema  over 
the  dorsum  of  each  hand,  this  has  extended  well  up  on  the  fore- 
arms, has  become  pigmented  and  has  been  associated  with  burning 
and  pain.  Coincident  with  this  there  has  been  an  exacerbation  of  the 
mental  and  nervous  symptoms.  There  has  developed  a  pulse  rate 
out  of  proportion  to  the  temperature. 

On  examination  the  patient  presents  marked  emaciation  and  asthe- 
nia. Weight,  60  pounds ;  average  weight,  100  pounds.  Hemoglobin, 
75  per  cent. 

There  is  a  dark,  dry,  pigmented  eruption  on  the  backs  of  both 
hands  extending  well  up  on  the  backs  of  both  forearms.  There  are 
marked  mental  and  nervous  symptoms.  Muscular  reflexes  are  in- 
creased. 

Transfusion — July  3,  1909.    The  donor  is  a  strong,  healthy  male 
adult,  a  brother  of  the  patient.    The  donor  has  never  had  pellagra. 
There  was  a  good  transfer  of  blood  for  thirty  minutes.    The  donor  • 
had  an  attack  of  syncope  upon  leaving  the  operating  room. 


1 63 

July  4th,  twenty- four  hours  isfter  the  operation,  there  are  marked 
signs  of  improvement. 

July  7th,  four  days  after  the  operation,  the  skin  lesions  began  to 
desquamate. 

The  marked  nervous  and  mental  symptoms  began  to  rapidly  dis- 
appear and  were  almost  entirely  absent  within  a  week  from  the  day 
of  transfusion.  The  sore  mouth  disappeared  within  four  days,  the 
bowel  movements  were  less  frequent  after  the  fourth  day,  and  en- 
tirely disappeared  within  three  weeks. 

July  13th,  ten  days  after  the  operation,  the  patient  weighs  68  1-2 
pounds,  a  gain  of  8  1-2  pounds. 

The  patient  returned  home  and  has  steadily  improved.  Three 
months  after  the  operation  she  states  that  she  is  stronger  and  has 
gained  about  1 5  pounds ;  that  there  are  neither  eruption,  diarrhoea 
nor  mental  symptoms. 

This  patient  has  made  a  gradual  improvement  from  the  day  of 
operation,  and  will  eventually  recover  entirely. 

Case  3. — Annie  H.,  age  42 ;  white.  Referred  by  Dr.  P.  A.  Trice, 
Morvin,  Ala. 

One  year  ago  this  patient  had  an  attack  of  diarrhoea  of  six  months' 
duration*  there  is  also  an  indefinite  history  of  an  erythema  over  the 
backs  of  both  hands  at  this  time.  There  was  marked  asthenia, 
anemia  and  emaciation  during  the  attack.  There  is  a  history  of 
nervous  excitability  but  no  mental  disturbances.  There  is  no  history 
of  sore  mouth. 

On  examination  the  patient  shows  indefinite  signs  of  an  old  de- 
squamative skin  lesion  over  the  backs  of  both  hands,  increased 
reflexes,  asthenia,  nervous  excitability  and  a  marked  grade  of 
anemia.  There  is  considerable  emaciation,  the  patient  stating  that 
she  has  lost  thirty  or  forty  pounds  in  weight. 

Transfusion — July  18,  1909.  The  donor  is  a  healthy  adult,  male 
(patient's  husband). 

There  was  a  good  transfer  of  blood  for  twenty  minutes. 

July  2 1st,  three  days  after  the  operation,  the  patient  shows  definite 
signs  of  improvement. 

Twelve  weeks  after  the  operation  her  physician  writes  that  her 
physical  condition  is  better;  that  she  has  gained  fifteen  pounds  in 
weight ;  that  her  anemia  is  much  improved.  The  patient  herself  says 
that  she  is  stronger  than  she  has  been  for  the  past  three  years. 

Case  4. — Mrs.  T.,  age  27 ;  white.  Referred  by  Dr.  Bailey,  Demop- 
olis,  Ala. 


164 

This  patient  developed  an  erythema  over  the  backs  of  both  hands 
six  weeks  ago;  this  extended  to  the  forearms,  elbows,  sieves  of  the 
neck  and  upon  the  face.  This  has  been  associated  with  a  marked 
stomatitis  and  nausea  in  the  past  three  days.  The  stomatitis  has 
been  so  severe  in  the  past  few  days  as  to  seriously  interfere  with 
feeding.  There  has  been  a  profuse  diarrhoea  and  an  increasing  as;l;e- 
nia,  anemia  and  emaciation.  The  nervous  symptoms  have  been  pro- 
nounced in  the  last  few  days. 

On  examination  the  patient  is  found  to  be  in  a  practically  moribund 
condition ;  an  ulcerating  and  deeply  pigmented  eruption  covers  the 
dorsal  surfaces  of  both  hands,  forearms  and  the  sides  of  the  neck. 
There  is  a  deeply  pigmented  mask  over  the  entire  face.  There  is 
ulceration  of  the  mouth,  a  swollen,  blackened  tongue  protrudes  from 
the  parched  and  ulcerated  lips,  from  which  there  constantly  drools 
forth  a  fetid,  slimy  discharge.  This  pigmentation  extends  over  the 
legs  and  feet  as  well. 

The  patient  is  markedly  emaciated  and  presents  a  terminal  stage 
of  anemia.  The  reflexes  are  almost  absent;  there  is  incontinence, 
marked  anemia  and  frequent  emesis.    Pulse  150 160. 

Transfusion — July  11,  1909.  Two  donors.  The  first  donor  is  a 
white  adult  female  who  recovered  a  few  weeks  ago  from  a  severe 
attack  of  pellagra.  A  good  transfer  of  blood  was  obtained  for  ten 
minutes,  when  the  transfusion  was  discontinued  on  account  of  the 
weakened  condition  of  the  donor. 

A  second  transfusion  was  performed  from  a  healthy  adult  male 
(the  patient's  husband),  who  has  never  had  pellagra,  A  good  trans- 
fer of  blood  was  obtained  for  fifteen  minutes.  The  transfusion  Avas 
then  discontinued  on  account  of  the  weakened  condition  of  the 
recipient. 

This  patient  was  in  a  hopeless  condition  at  the  time  of  operation 
and  showed  no  signs  of  improvement  after  the  operation.  The 
patient  died  three  hours  after  the  operation. 

Case  5. — Mrs.  B.,  age  58;  white.  Referred  by  Dr.  Bondurant, 
Mobile,  Ala. 

This  patient  was  treated  by  her  family  physician,  Dr.  O.  G.  Bruner, 
of  Fort  Deposit,  Ala.,  for  a  persistent  case  of  diarrhoea  extending 
over  a  period  of  two  years.  One  year  ago  there  appeared  an  erup- 
tion over  the  backs  of  both  hands,  this  was  followed  by  desquamation. 
This  eruption  reappeared  in  the  spring  of  1909,  about  six  months 
before  transfusion,  and  a  few  weeks  before  transfusion  the  patient 
developed  marked  mental  and  nervous  symptoms. 


i65 

On  examination  there  are  remains  of  a  desquamating  skin  lesion 
over  both  hands  and  forearms.  There  are  constant  involuntary  mus- 
cle tremors,  increased  reflexes  and  the  mental  condition  is  that  of 
constant  delusions,  and  at  times  a  muttering  delirium.  There  is 
asthenia  and  marked  emaciation ;  weight,  70  pounds ;  average  weight, 
100  pounds. 

Transfusion — July  17,  1909.  The  donor  is  a  healthy  adult  male 
(the  patient's  son),  who  has  never  had  pellagra.  There  was  a  good 
transfer  of  blood  for  twenty-five  minutes. 

July  18.  Twenty-four  hours  after  the  operation  the  nervous  and 
mental  condition  is  improved.  This  patient  gained  eight  and  one- 
half  pounds  in  the  first  week  and  went  on  to  a  rapid  recovery. 
Eleven  weeks  after  the  operation  the  son  writes  that  the  mental  con- 
dition seems  perfect;  there  are  no  symptoms  of  pellagra  and  there 
has  been  a  gain  of  thirty-four  pounds  in  weight. 

Case  6. — ^Mrs.  H.,  age  50 ;  white.  Referred  by  Dr.  Sarah  A.  Cas- 
tle, Meridian,  Miss. 

This  patient  has  had  attacks  of  diarrhoea,  associated  with  sore 
mouth,  for  the  past  two  years.  Four  months  ago  the  patient  had  an 
attack  of  diarrhoea  of  two  weeks'  duration,  and  this  was  followed  by 
a  stomatitis  that  has  grown  very  severe  and  persists.  An  eruption 
appeared  on  the  hands  about  four  weeks  ago  and  extended  over  the 
forearm,  face  and  legs.  There  have  been  marked  nervous  and  men- 
tal symptoms  for  the  past  six  weeks.  This  condition  has  been  that  of 
acute  delirium  at  times.  There  have  been  severe  sensory  and  motor 
symptoms,  and  incontinence  of  the  bowels,  a  condition  present  for 
about  a  week. 

On  examination  there  is  found  an  almost  hopeless  anemia  and 
emaciation.  A  desquamating  skin  lesion  extends  over  the  hands, 
arms,  legs  and  face.  There  is  a  drooling,  fetid  discharge  from  the 
mouth,  a  marked  stomatitis,  incontinence  of  the  bowels,  and  at  times 
a  low  muttering  delirium. 

Transfusion — July  22,  1909.  The  donor  is  an  arteriosclerotic, 
plethoric,  male  (the  patient's  husband),  who  has  never  had  pellagra; 
age,  about  60.  The  anastamosis  was  accomplished  with  a  great  deal 
of  difficulty  because  of  the  extreme  degree  of  atheroma  present  in 
the  donor's  radial  artery.  There  was  only  a  very  small  amount  of 
blood  transferred. 

Transfusion — August  17,  1909.  This  patient  made  no  definite 
signs  of  improvement  and  was  again  transfused  twenty-six  days  after 


i66 

the  first  attempt.  At  this  time  she  was  in  the  same  physical  condi- 
tion, except  for  a  much  more  severe  anemia. 

The  donor  is  a  female,  age  i8  (the  patient's  daughter).  This 
donor  recovered  from  a  definite  attack  of  pellagra  two  years  ago. 
There  was  a  good  transfer  of  blood  for  twenty-five  minutes. 

August  1 8,  1909,  twenty-four  hours  after  the  operation,  there  is 
an  aggravation  of  the  mental  symptoms. 

August  23,  1909.  One  week  after  the  operation  the  patient  has 
shown  no  definite  signs  of  improvement,  except  that  the  stomatitis 
has  cleared  up  to  some  extent.  Death  occurred  four  weeks  after 
transfusion. 

Case  7. — Mr.  G.,  age  30;  white.  Referred  by  Dr.  J.  L.  Bryan, 
Greenville,  Ala. 

Six  months  ago  this  patient  developed  an  erythema,  followed  by 
a  pigmentation  over  the  backs  of  both  hands  and  forearms.  During 
this  period  there  has  developed  a  severe  diarrhoea,  mental  deteriora- 
tion and  an  extreme  degree  of  emaciation. 

On  examination  this  patient  presents  marked  asthenia  and  anemia. 
There  are  pronounced  motor  and  sensory  disturbances,  a  desquamat- 
ing skin  lesion  still  presents  over  the  backs  of  both  hands  and  fore- 
arms. The  sore  mouth  and  diarrhoea,  while  present,  are  not  severe 
at  this  time. 

Transfusion — July  25,  1909.  The  donor  is  a  14-year-old  boy  (the 
patient's  nephew),  who  has  never  had  pellagra.  Because  of  the 
extreme  restlessness  of  the  youth  only  a  small  amount  of  blood  was 
transfused  in  the  course  of  twenty  minutes. 

July  26th,  twenty-four  hours  after  the  transfusion,  the  patient 
shows  no  signs  of  improvement. 

This  patient  became  steadily  worse  and  died  August  20,  1909, 
twenty-six  days  after  the  transfusion. 

This  case  was  not  transfused  with  any  appreciable  amount  of  blood. 

Case  8. — Mrs.  S.  H.,  age  30;  white.  Referred  by  Dr.  Armstead, 
Nanafalia,  Ala. 

This  patient  had  a  severe  attack  of  diarrhoea  about  one  year  ago, 
associated  with  sore  mouth  and  marked  nervous  and  mental  symp- 
toms— duration,  two  months.  There  were  no  skin  lesions  at  this 
time. 

The  present  attack  began  three  weeks  ago  with  an  erythema  on 
the  backs  of  the  hands  and  wrists.  This  went  on  to  the  induration, 
pigmentation  and  desquamation  characteristic  of  the  disease.  This 
attack  is  associated  with  a  severe  stomatitis.    During  this  attack  the 


167 

patient  has  had  marked  nervous  and  mental  symptoms  and  has  be- 
come emaciated  and  anemic. 

On  examination  there  are  the  remains  of  a  desquamating  skin 
lesion  over  the  dorsum  of  the  hands,  wrists,  forearms  and  elbows. 
There  is  stomatitis  and  a  mild  grade  of  diarrhoea.  The  patient  has 
lost  about  forty  pounds  in  weight. 

Transfusion — July  25,  1909.  The  donor  is  a  healthy  adult  male 
(the  patient's  husband),  who  has  never  had  pellagra.  There  was  an 
excellent  transfer  of  blood  for  fifteen  minutes,  when  the  operation 
was  discontinued,  as  the  recipient  showed  signs  of  cocainism. 

July  26th,  twenty-four  hours  after  the  operation,  the  patient  shows 
an  improvement  in  her  mental  and  nervous  condition. 

Ten  weeks  after  the  operation  her  physician  writes  that  the  patient 
has  improved  wonderfully  since  the  operation.  There  is  no  skin 
lesion,  no  sore  mouth,  no  diarrhoea.  The  mental  and  nervous  symp- 
toms are  much  improved.  The  patient  says  that  she  feels  better  than 
she  has  in  five  years.  She  has  gained  about  twenty  pounds  in  weight 
and  "feels  100  per  cent,  better  than  before  the  operation,"  according 
to  her  physician's  statement. 

Case  9. — Mrs.  M.,  age  36;  white.    Referred  by  Dr.  McMillan. 

This  patient  has  had  attacks  of  severe  diarrhoea  every  spring  for 
six  or  seven  years.  These  attacks  were  of  about  one  month's  dura- 
tion and  cleared  up  without  medical  treatment. 

Eighteen  months  ago  the  patient  developed,  for  the  first  time,  an 
eruption  over  the  backs  of  the  hands.  This  eruption  lasted  about  a 
month  and  went  on  to  desquamation  without  pigmentation.  At  this 
time  the  patient  developed  a  sore  mouth  and  salivation,  which  was 
present  about  one  month.  The  patient  had  another  attack  of  diar- 
rhoea about  four  months  ago ;  at  this  time  she  was  anaemic,  emaciated 
and  showed  marked  nervous  symptoms. 

Four  weeks  ago  sore  mouth  again  appeared,  associated  with  diar- 
rhoea, anaemia,  emaciation,  asthenia  and  an  erythema,  which  extended 
over  the  backs  of  both  hands  well  up  on  the  forearms.  This  eruption 
became  pigmented  and  desquamated.  At  this  time  the  nervous  symp- 
toms were  aggravated  and  there  developed  a  mild  grade  of  dementia. 

An  interesting  point  in  this  case  is  that  there  was  a  suspicion  of 
diabetes  for  several  years,  and  the  patient  was  placed  on  a  diet  con- 
sisting largely  of  corn  bread. 

On  examination  she  presents  the  remains  of  a  desquamating  skin 
lesion  over  the  dorsal  surfaces  of  both  arms  and  hands.  There  is 
asthenia,  emaciation  and  anemia.    Hemoglobin,  70  per  cent.    Weight, 


i68 

74  pounds;  average  weight,  lOO  pounds.  There  is  a  profuse  diar- 
rhoea.   The  mental  condition  at  times  is  that  of  a  mild  dementia. 

Transfusion — October  i8,  1909.  The  donor  is  a  healthy  adult, 
male  (the  patient's  husband),  who  has  never  had  pellagra.  There 
was  a  good  transfer  of  blood  for  thirty  minutes. 

October  19th,  twenty-four  hours  after  the  operation,  there  is  a  dis- 
tinct improvement  in  the  mental  condition. 

October  25th,  one  week  after  the  operation,  the  patient  has  im- 
proved markedly  in  general  condition;  the  mental  symptoms  have 
disappeared,  the  appetite  is  much  improved,  and  the  patient  has 
gained  seven  and  one-half  pounds  in  weight. 

TRANSFUSION  IN  PELLAGRA. 

It  must  be  noted  that  the  only  medicinal  agents  used  in  the  recov- 
ered cases  were  tonics  of  strychnine,  forced  feeding,  and  in  some 
cases  carbonate  of  iron. 

In  every  case  benefited  by  transfusion  the  improvement  was  imme- 
diate, as  shown  by  marked  gain  in  weight  within  the  first  week — in 
one  instance,  as  much  as  eight  and  one-half  pounds.  All  the  patients, 
two  months  after  transfusion,  are  either  apparently  cured  or  mark- 
edly improved,  and  have  gained  from  five  to  thiry-five  pounds  in 
weight. 

Of  the  fatal  cases,  case  No.  (4)  was  moribund  at  the  time  of  oper- 
ation, and  died  three  hours  after  transfusion;  case  No.  (7)  received 
no  appreciable  amount  of  blood  on  transfusion;  case  No.  (6)  re- 
ceived practically  no  blood  at  the  first  operation,  and  at  the  second 
transfusion,  when  a  pellagrous  donor  was  used,  while  she  received  a 
good  flow  of  blood,  her  condition,  we  felt,  was  hopeless. 

We  suggest  the  following  conclusions  : 

(i.)  Transfusion  offers  a  means  of  combatting  the  anemia,  stim- 
ulating the  recuperative  functions  and  perhaps  of  furnishing  anti- 
toxic substances  to  pellagrins. 

(2.)  The  lessened  mortality  and  marked  improvement  in  trans- 
fused pellagrins  leads  us  to  anticipate  the  establishment  of  a  serum 
therapy  in  the  disease. 

(3.)  Transfusion  may  be  offered  as  a  surgical  therapeutic  proce- 
dure in  pellagrous  cases  pending  the  perfection  of  a  successful  serum 
therapy. 

REFERENCES. 

(1)  Tizzoni.     Reference  from  Wood.      "Jour.  Am.   Med.   Assc."   LIII.   No    4. 

(2)  Lombroso.     Reference  from  Watson.     "N.  T.  Med.  Jour.",  May  8,  1909. 

(3)  Babes.  Reference  from  Lavinder.  "PeUagra:  A  Precis."  Report 
P.  H.  &  M.  H.   S.   1907. 


169 


(4)  Giovanni  and  Gatti.      "Richerche      sulle    proprieta    emolitiche    e    cito- 
precipitanti  del  siero  di  sangue  de  pellagroso."     1909. 

(5)  D'Ormea.     Reference  same  as  (4). 

(6)  and    (8)    Antonini    and   Marianni.      "Contributo    alio    Studio    dello    sier 
oterapia  nella  Pellagra."     1904. 

(7)  Cole.     "The  Transfusion  of  Blood  as  a  Therapeutic  Agent  with  Report 
of  Transfusion  in  a  Case  of  Pellagra."     S.  Med  Jour.  April,  1909. 

(9)    Wood  and  Green.     Personal  communication  dated  Oct.   12,   1909. 
(10)   McCafferty   and    Tisdale.      Personal   communication    from    Dr.    Tisdale, 
dated  Oct.   14,  1909. 

(11)   Liombroso.     Personal  communication  dated  July  29,   1909. 


DISCUSSIONS   ON   PAPERS   OF   DRS.   BASS,   FOX  AND 

COLE. 

Dr.  J.  H.  Taylor,  Columbia,  South  Carolina:  Regarding  the 
use  of  serum  in  the  treatment  of  pellagra,  I  wish  to  say  that  while 
actual  transfusion  according  to  Crile's  method  was  first  done  by  Dr. 
Cole,  so  far  as  I  have  read,  yet  two  Italians,  Antonini  and  Mariani, 
some  years  ago  noted  in  their  experiments  on  animals  that:  (i) 
Those  poisoned  by  the  toxines  of  com  acquired  a  certain  degree  of 
immunity  against  the  toxic  action  of  serum  from  a  pellagrous  patient, 
and  also  against  new  injections  of  toxic  extracts  of  corn.  (2)  The 
toxic  action  of  the  serum  from  a  pellagrin  is  neutralized  by  the 
simultaneous  or  successive  injection  of  the  serum  of  a  cured  pella- 
grin. (3)  The  addition  of  serum  from  the  blood  of  a  cured  pella- 
grin in  certain  proportions  to  that  from  an  active  case  of  pellagra 
exercises  a  specific  relieving  antitoxic  action.  (4)  The  serum  from 
the  blood  of  a  cured  pellagrin  exerts  an  antitoxic  action  when 
injected  subcutaneously  into  cases  of  typhoid  pellagra.  Moreover, 
this  action  is  in  direct  proportion  to  the  degree  of  natural  immunity 
acquired  by  the  cured  pellagrin,  since  the  best  results  have  been 
obtained  by  using  the  serum  from  a  convalescing  typhoid  pellagrin, 
They  demonstrated  this  last  observation  on  four  cases  of  typhoid 
pellagra,  three  of  whom  showed  a  prompt,  marked  and  rapid 
improvement  with  ultimate  recovery,  and  the  fourth  case  began 
improvement,  but  owing  to  the  donors  passing  from  under  their 
control  no  more  serum  could  be  obtained  and  the  case  died. 

In  view  of  these  facts  it  would  seem  that  actual  transfusion  of 
blood  should  hold  out  to  us  splendid  possibilities. 

Dr.  C.  C.  Bass,  New  Orleans,  Louisiana :  I  wish  to  speak  with 
reference  to  the  paper  of  Dr.  Fox  and  to  further  emphasize  the  fact 
that  his  experiments  with  complement  fixation  in  pellagra  differ 
materially  from  mine  in  that  he  used  as  antigen  extract  of  syphilitic 


I/O 

liver  and  normal  hearts  and  kidneys.  These  do  not  yield  a  strong 
solution  of  lecithin.  My  paper  referred  only  to  results  with  lecithin 
as  antigen.  When  using  the  same  sort  of  antigens  as  he  did  I  got 
about  the  same  results  as  he  did.  Complement  fixation  experiments 
I  have  done  using  many  different  antigens,  including  various  extracts 
from  different  tissues  and  organs  from  pellagrins,  as  well  as  cultures 
isolated  from  patients  and  also  from  corn  meal,  have  all  been 
reserved  for  future  reports  and  not  considered  worth  while  to  include 
in  the  paper  here  read.  The  only  explanation  so  far  suggested  to 
me  for  the  fact  that  lecithin  serves  better  for  antigen  in  pellagra  than 
organ  extract  is  that  because  of  the  destructive  process  in  the 
nervous  system,  a  large  amount  of  lecithin  is  set  free  and  there  may 
be  formed  a  response  to  this  increased  lecithin  content  of  the  blood 
much  anti-lecithin  amboceptor. 

Dr.  W.  B.  Young,  Rock  Hill,  S.  C. :  With  reference  to  the  paper 
of  Dr.  Cole  I  would  like  to  know  what  preparation  of  iron  was  used 
and  how  it  was  given.  Dr.  Babcock  used  arsenite  of  iron  hypoder- 
mically  and  did  not  obtain  any  results.  We  have  been  using  it  and 
it  has  seemingly  improved  the  general  condition.  I  have  used  it  in 
six  or  seven  cases  and  the  condition  of  the  patients  have  improved  so 
far. 

Dr.  Fox  (closing  the  discussion)  :  I  am  very  pleased  to  have 
heard  from  Dr.  Bass,  who  has  only  obtained  positive  reactions  when 
he  used  lecithin  as  antigen,  I  feel  that  our  results  are  somewhat 
discordant  because  he  has  six  positive  reactions  in  six  cases,  and  I 
only  obtained  seven  reactions,  most  of  them  weak,  in  twenty-nine 
cases.  As  he  states  this  reaction  only  occurs  when  he  uses  lecithin 
as  antigen  and  it  does  not  occur  when  he  uses  other  extracts,  includ- 
ing extracts  of  syphilitic  organs,  so  that  I  feel  that  our  results  are 
not  really  as  antagonistic  as  they  might  appear  to  be. 


171 


REPORT  OF  PELLAGRA  AT  NASHVILLE,  TENN. 

J.    M.    KING^   B.   S.J   M.   D. 
Professor  of  Dermatology,  Vanderbilt  University. 

In  presenting  this  paper  I  do  not  propose  to  discuss  pellagra  in  a 
general  way,  but  shall  deal  with  the  subject  as  observed  at  Nash- 
ville, Tenn. 

There  were  two  groups  of  patients,  one  occurring  in  the  Baptist 
Orphanage,  consisting  of  seventeen  cases,  the  other,  consisting  of 
two  cases,  which  were  found  in  the  country  fourteen  miles  from 
the  city,  and  one  single  case.  In  dealing  with  the  orphanage,  I  wish 
to  present  as  near  as  possible  the  order  in  time  of  the  occurrence 
of  the  disease  among  the  children.  In  the  fall  of  1905  a  family  of 
four  children,  cases  Nos.  i,  2,  3  and  4,  were  admitted  from  Newport, 
Tenn.,  with  the  ages  of  6,  8,  10  and  12  years.  They  came  from  most 
destitute  circumstances.  Very  little  of  their  past  history  could  be 
obtained,  either  from  their  parents  or  their  physician,  who  failed  to 
answer  any  letter  of  inquiry.  Upon  admission  the  youngest  child, 
Addie  M.,  case  No.  i,  presented  manifestations  of  some  skin  disease 
to  which  very  little  attention  was  paid.  The  children  remained  at 
the  orphanage  during  the  winter  and  the  next  spring  this  youngest 
child  was  allowed  to  play  out  in  the  yard  in  a  low-necked  dress  and 
short  sleeves.  After  a  few  days  an  erythematous  eruption  was 
observed  on  the  exposed  surface,  the  face,  neck,  shoulders,  backs  of 
the  hands  and  feet.  It  was  regarded  as  sunburn  by  those  in  charge. 
The  eruption  became  more  aggravated  during  the  summer,  but 
improved  in  the  fall  and  winter.  During  the  winter  the  child  was 
away  from  the  orphanage  for  a  while,  but  was  returned  sick.  In 
the  spring  the  eruption  on  the  skin  reappeared  and  was  associated 
from  time  to  time  with  an  uncontrollable  diarrhoea,  stomatitis  and 
much  emaciation.  At  this  stage  of  the  disease  in  this  child,  measles 
broke  out  in  the  institution,  and  it  is  reported  that  she  contracted 
the  disease  and  did  not  recover.  The  diagnosis  of  pellagra  had  not 
been  made  up  to  this  time. 

The  next  youngest  child,  in  this  family,  Roy  M.,  case  No.  2, 
developed  a  skin  eruption  during  the  summer  of  1907,  rather  mild 
in  type  at  first.  He  passed  through  the  winter  and  during  the  spring 
and  summer  months  of  1908  the  most  aggravated  pellagrous  erup- 


172 

tion  developed,  erythematous,  bullous ;  later,  with  thickened  skin, 
cracked  and  very  rough  on  the  hands  and  feet.  The  eruption 
extended  over  the  face,  neck  and  shoulders,  over  the  hands  and  fore- 
arms to  the  elbows,  over  the  tops  of  the  feet  and  up  the  legs  to  the 
knees.  This  case  progressed  and  died  in  September,  1909.  In 
June,  1908,  is  the  time  when  I  first  examined  the  children,  and  the 
disease  had  further  progressed  in  this  boy  than  in  any  of  the  group 
then  living,  his  younger  sister  being  dead.  His  sister,  case  No.  3, 
Annie  M.,  next  older,  and  his  brother,  case  No.  4,  Jesse  M.,  14 
years  of  age,  had  presented  mild  skin  manifestations  during  the 
summer  of  1908,  the  girl  having  an  erythematous  eruption  on  the 
face,  hands  and  feet,  while  the  boy  had  a  mild  erythematous  eruption 
only  on  the  feet.  At  this  time,  in  June,  1908,  when  I  first  saw  the 
cases  and  made  a  diagnosis  of  pellagra,  twelve  children  were 
affected,  showing  the  eruption  on  the  hands,  feet,  and  some  on  the 
face.  As  a  group  they  had  not  suffered  from  any  perceptible  gastro- 
intestinal disturbances,  except  case  No.  2,  who  had  had  a  few  spells 
of  diarrhoea,  and  there  were  no  nervous  manifestations. 

Case  No.  5,  Charley  T.,  had  the  eruption,  rather  mild  in  form,  over 
the  face  and  neck  and  shoulders,  on  the  backs  of  the  hands,  a  little 
above  the  wrists,  and  on  the  tops  of  the  feet  to  his  knees,  and  in  this 
respect  he  was  as  far  advanced  in  the  disease  as  case  No.  2.  He 
was  a  stronger  boy,  both  mentally  and  physically,  than  case  No.  2. 
At  this  time  I  outlined  a  general  course  of  treatment  which  was 
carried  out  at  the  orphanage  and  at  St.  Thomas  Hospital,  the  author- 
ities of  the  orphanage  allowing  cases  2  and  5  to  be  taken  there  for 
treatment,  rather  as  test  cases.  These  two  boys  were  given  daily 
a  warm  bath  with  green  soap,  and  anointed  with  vaseline  and  were 
not  allowed  to  be  exposed  to  the  sun.  They  were  given  full  diet 
and  the  medicinal  treatment  consisted  of  Fowler's  Solution,  one 
drop,  and  elixir  of  iron,  quinine  and  strychnine — one-half  a  dram 
after  meals.  The  eruption  on  both  boys  readily  cleared  up.  They 
improved  in  appearance  and  after  ten  days  they  were  apparently  well, 
wuth  the  exception  of  very  slight  redness  over  some  of  the  parts 
affected.  Case  No.  2  was  troubled  with  diarrhoea  while  in  the  hos- 
pital. The  two  boys  were  returned  to  the  orphanage,  where  they 
remained  for  several  weeks  during  which  time  the  eruption  reap- 
peared, but  in  a  more  mild  form  than  at  first.  The  children  who  had 
been  treated  at  the  home  had  also  improved  on  the  same  line  of 
treatment. 


173 

In  the  latter  part  of  the  fall  of  1908  the  management  of  the 
orphanage  secured  a  separate  building,  the  annex,  and  placed  the 
affected  children  there  for  the  winter  and  spring,  in  charge  of  a 
special  attendant  and  under  my  medical  care.  The  object  of  this 
segregation  was  to  place  the  children  in  such  surroundings  that  they 
could  have  more  careful  attention  in  the  way  of  medical  and  hygienic 
treatment,  and  because  the  disease  was  thought  at  this  time  to  be 
infectious  or  to  be  transmitted  in  some  unknown  way.  While  the 
food  at  the  orphanage  had  at  all  times  been  excellent — really  as  good 
as  that  taken  by  the  average  individual — still  we  thought  by  giving 
a  more  nutritious  diet  they  would  be  benefited.  The  medical  treat- 
ment consisted  of  arsenic  in  small  doses  with  iron,  quinine  and 
stychnine  and  lactic  acid  bacillus  tablets,  given  after  meals.  Each 
child  received  a  daily  warm  bath  with  green  soap  and  the  erythe- 
matous parts  were  kept  covered  night  and  day  with  an  ointment  of 
boric  acid,  lanolin  and  vaseline.  During  the  winter  months  the 
eruption  disappeared  from  all  the  children  except  case  No.  2,  who 
constantly  showed  some  skin  signs  of  the  disease.  None  of  the 
children  developed  any  nervous  symptoms  or  gastro-intestinal  mani- 
festations, except  case  No.  2,  who  gradually  grew  worse,  his  mental 
state  becoming  more  impaired,  and  his  gait  more  ataxic. 

In  the  spring  of  1909  two  more  children  of  the  orphanage,  eight 
and  nine  years  of  age,  showed  a  very  slight  erythematous  eruption 
and  were  sent  to  the  annex.  In  the  early  spring  case  No.  5  ran 
away  from  the  annex  and  returned  to  his  home  in  Knoxville,  Tenn. 
In  the  spring  of  1909,  as  the  warmer  weather  came  on,  case  No.  2 
grew  much  worse  in  every  respect  of  the  disease,  and  case  No.  6, 
Charley  M.,  developed  a  severe  erythematous  eruption  over  the  lower 
part  of  the  face,  neck,  the  backs  of  the  hands,  and  tops  of  the  feet, 
with  some  fever.  Case  No.  2  went  into  such  a  hopeless  condition  that 
we  thought  he  would  not  live  longer  than  a  few  days.  However, 
with  liquid  diet  and  no  medicine,  he  slowly  improved  until  he  was 
able  to  walk,  and  lived  about  two  months. 

Case  No.  3,  Anna  M.,  developed  a  mild  erythema  on  the  feet  and 
legs.  Jesse  M.,  case  No.  4,  has  shown  no  signs  of  the  disease  since 
the  summer  of  1908. 

At  this  stage  of  the  situation,  about  the  middle  of  the  summer  of 
1909,  the  authorities  of  the  orphanage  petitioned  the  county  to  take 
charge  of  the  cases,  and  they  were  transferred  to  a  home  five  miles 
from  the  city  under  the  control  of  the  county  and  the  county  health 
officer.  Dr.  B.  G.  Tucker,  with  whom,  in  consultation,  I  have  seen 


174 

the  children  several  times.  Following  the  suggestion  of  Dr.  Lavin- 
der  we  put  the  entire  group  on  daily  salt  rubs  and  gave  salt 
internally. 

At  the  county  home  case  No.  2,  Roy  M.,  was  placed  in  separate 
quarters  from  the  other  children,  and  with  an  adult  case  of  pellagra 
in  the  last  stages.  The  boy's  condition  at  this  time  was  extremely 
pitiable.  He  was  pale,  emaciated,  extremely  weak  mentally,  and  his 
mouth  so  sore  that  he  could  scarcely  take  any  kind  of  food,  and  was 
suffering  with  an  uncontrollable  diarrhoea.  At  times  he  grew  deli- 
rious and  would  cry  out  for  hours  at  the  time.  During  his  lucid 
moments  he  would  say  that  he  was  suffering  excrutiating  pain  from 
head  to  foot.  During  the  last  two  months  he  had  a  marked  coarse 
tremor  in  both  hands,  and  a  very  slight  ataxic  gait.  Death  followed 
in  a  few  days. 

An  autopsy  was  held  by  Prof.  Wm.  Litterer  with  the  following 
report : 

"Extreme  emaciation  and  absence  of  adipose  tissue.  The  external 
lesions  had  markedly  improved  from  several  months  ago. 

"The  lungs  (hypostatic),  heart  flabby  and  small,  valves  normal. 
Liver  (enlarged  slightly),  spleen  three  times  larger  than  normal  and 
very  dark  and  friable.  Kidneys  were  slightly  congested,  normal  in 
size  and  capsule  stripped  easily.  The  stomach  was  enlarged  and  very 
thin.  In  places  it  appeared  as  if  it  had  no  mucous  membrane.  No 
blood  found  in  stomach.  In  the  jejunm,  ileum,  colon  there  was  a 
marked  thinning  of  the  mucous  membrane.  Blood  was  found  in  the 
entire  intestines.  In  a  few  areas  the  wall  of  the  intestine  was  so  thin 
that  it  gave  the  appearance  of  an  erosion. 

"In  opening  the  spinal  cord  1  was  struck  with  the  fragility  of  the 
bones.  The  spinal  cord  showed  an  inflammation  and  thickening  of 
the  dura  mater. 

MICROSCOPICAL. 

"(i)   Lungs  are  hypostatic,  congested. 

"(2)  Heart  muscle  undergoing  fatty  degeneration  in  areas  while 
in  others  an  atrophic  change  has  taken  place. 

"(3)  Liver  shows  it  to  be  cloudy  swelHng,  fatty;  also  there  is  an 
excessive  pigmentation  of  the  cells  of  the  liver. 

"(4)  Spleen  shows  a  marked  hyperplasia  and  cloudy  swelling 
with  some  pigmentation  of  cells. 

"(5)  Stomach  and  intestines  show  a  marked  thinning  of  the 
mucous  membrane  with  congestion  in  areas.  (Further  study  will 
be  given  this.) 


175 

"(6;  In  the  spinal  cord  is  found  a  degeneration  of  the  posterior 
column  differing  from  that  of  tabes  in  showing  no  involvement  of 
the  posterior  roots.  There  is  also  found  in  this  case  a  degeneration 
of  the  cells  in  Qark's  column;  also  changes  in  the  large  Betz  cells 
of  the  ant,  horn. 

"Cultures  were  made  from  heart  blood,  liver  and  spleen  with  nega- 
tive results. 

"The  Wasserman  reaction  was  positive." 

The  next  worse  case,  Charles  M.,  No.  6,  at  this  time  in  August, 
1909,  showed  some  eruption,  had  a  slow  fever,  was  stupid  and  would 
stay  away  from  the  other  children.  He  was  put  on  Donovan's  Solu- 
tion and  fed  with  care.  After  a  few  weeks  he  was  very  much 
improved  in  appearance,  the  fever  and  eruption  had  disappeared,  his 
appetite  was  good,  and  he  was  taking  on  weight.  He  grew  more 
playful  and  would  take  part  in  the  games  with  the  children  and  was 
apparently  well.  I  saw  him  on  October  28th  and  observed  that  he 
had  failed  to  a  certain  extent,  he  had  lost  weight,  and  expressed  his 
feeling  as  if  he  was  drunk  or  dizzy.  Outside  of  this  he  was  appar- 
ently well. 

Case  No.  3,  Anna  M.,  on  October  28th,  showed  a  very  mild  ery- 
thema on  the  sides  of  the  neck  and  backs  of  the  hands,  which 
appeared  upon  slight  exposure  to  the  sun.  With  these  two  excep- 
tions, the  children  as  a  group  were  apparently  in  good  health. 

I  shall  next  discuss  the  second  group  consisting  of  a  man  and  a 
woman  who  lived  within  a  short  distance  of  each  other,  in  the 
country,  fourteen  miles  from  Nashville.  The  man,  case  No.  7,  H. 
as  he  reported,  had  some  eruption  during  the  summer  of  1908.  He 
retired  to  his  home  in  the  winter,  and  there  had  no  one  to  assist  him 
in  any  way.  He  got  his  food  the  best  he  could,  it  being  sent  in 
usually  by  his  neighbors.  Having  no  one  to  do  his  laundry,  the 
woman,  case  No.  8,  attended  to  it  for  him,  and  in  the  spring  of 
1909  she  developed  the  disease.  These  two  cases  were  first  seen 
by  Dr.  Lavinder  in  company  with  Drs.  Tucker  and  Core,  but  both 
called  to  see  me  at  different  times,  when  I  had  full  opportunity  to 
investigate  the  situation.  The  eruption  on  the  man  was  that  of  the 
usual  type.  He  was  very  much  broken  in  health,  was  very  weak, 
emaciated,  pale,  with  loss  of  appetite,  sore  mouth  and  an  inveterate 
diarrhoea,  conjunctivitis,  and  later  corneal  ulcers ;  there  were  no  dis- 
tinct nervous  symptoms,  except  mental  dullness.     He  was  finally 


176 

placed  in  the  county  home,  where  he  rapidly  grew  worse  and  died. 
He  had  had  syphilis  as  he  reported. 

Case  No.  8,  T\Irs.  W.,  when  first  seen  by  me  had  failed  very  much 
in  health ;  she  was  weak,  had  lost  weight,  and  complained  of  a  diar- 
rhoea. There  were  no  distinct  nervous  symptoms.  She  was  not  alert 
and  active  mentally.  The  eruption  was  on  her  face,  neck,  hands  and 
feet.  She  was  put  on  practically  the  same  treatment  that  had  been 
given  the  children.  She  improved  and,  as  was  reported  to  me  by 
Dr.  Tucker,  the  county  health  officer,  on  October  28th,  was  doing 
very  well  at  that  time. 

Case  No.  9,  Mrs.  H.  H.,  a  widow,  was  examined  by  me  on  October 
22nd,  with  the  opinion  that  the  case  was  pellagra.  The  eruption 
started  about  the  middle  of  March,  1909,  previous  to  which  she  had 
been  feeling  very  bad,  as  she  expressed  it.  She  said  she  had  no 
ambition  to  do  any  work,  and  tired  very  easily.  She  was  dizzy  and 
described  the  feeling  as  if  she  needed  calomel,  and  insisted  iipon  her 
doctor  giving  it  to  her,  although  her  bowels  were  constipated. 
After  the  administration  of  calomel,  she  had  a  terrific  diarrhoea  for 
four  weeks,  as  she  expressed  it.  The  mucous  membrane  of  her 
mouth  became  very  sore,  red  and  swollen,  and  finally  blebs  and 
ulcers  developed.  At  the  end  of  eight  weeks  she  went  to  bed.  The 
eruption  appeared  on  the  hands  three  weeks  after  the  sore  mouth 
began.  The  hands  were  red  and  swollen  with  the  formation  of 
blebs.  During  the  summer  her  condition  gradually  grew  worse.  At 
present  she  is  still  in  the  active  stage  of  the  disease,  with  its  accom- 
panying symptoms  and  signs. 

The  laborator}'  work  consisted  of  several  blood  examiinations ; 
examination  of  the  serus  exudate  from  blebs  on  Case  No.  2,  examin- 
ation of  feces  of  case  No.  2  for  uncinariasis  by  Dr.  Oughterson,  and 
at  my  suggestion,  Wasserman's  test  was  made  in  cases  Nos.  2,  3,  6 
and  7  by  Dr.  Wm.  Litterer.  These  examinations  were  negative 
except  the  Wasserman  in  case  No.  2,  which  was  positive.  In  case  No. 
7  it  was  positive,  but  the  patient  had  syphilis.  There  was  a  slight 
positive  reaction  in  No.  6.  It  was  negative  in  case  No.  3,  Anna  M. 
These  cases  are  the  first,  as  far  as  we  know,  that  have  been  sub- 
jected to  the  Wasserman  reaction. 


177 

"In  June,  1909,  the  blood  of  Anna,  Charles  and  Roy  was  obtained 
and  cultures  were  attempted  from  the  lesions.    The  result  follows : 

In  Anna — Case  3  : 

Red  blood  cells 4,200,000 

Hemoglobins 80% 

Whites 8,500 

Cultures  from  the  lesions  were  negative. 
In  Charles  M. — Case  No.  6: 

Red  blood  cells 4,080,000 

Hemoglobin 72% 

Whites 6,900 

Cultures  from  the  lesions  were  negative.    The  Wasser- 
man  reaction  was  negative. 
In  Roy — Case  No.  2  : 

Red  blood  cells 4,000,000 

Hemoglobin 70% 

Whites 13,000 

Cultures    from   lesions   proved   to   be   staphylococous 
pyogenes  aureus. 
Blood  cultures  were  obtained,  taking  10  c.  c.  of  blood  giving  nega- 
tive results  on  all  of  the  media  used.    The  Wasserman  reaction  was 
distinctly  positive  at  this  time.  (June.) 

September,  1909. 
Anna  shows  negative  Wasserman  1       at    v.*    '         f 

Charles  shows  doubtful  Wasserman  I  ■'^ 

Roy  shows  positive  Wasserman  J 

Hampton  shows  positive  Wasserman  i     History  of  syph. 

Blood  cultures  obtained  two  days  before  death  in  Hampton  Case, 
No.  7,  showed  the  staphylococcus  pyogenes  albus." 

In  commenting  upon  the  two  groups  above  reported,  the  first  con- 
sideration is,  has  there  been  any  transmission  of  the  disease  from 
one  case  to  another  through  food  or  any  other  way?  Is  the  disease 
infectious?  We  know  well  enough  the  opinions  of  the  authorities 
pro  and  con.  There  seems  to  be  absolutely  no  doubt  as  to  the 
diagnosis  of  these  cases.  In  the  orphanage  the  disease  was  first 
introduced  by  a  family  of  children  from  destitute  parents ;  later  on, 
up  to  1909,  other  cases  developed,  in  the  same  institution,  and  in 
children  from  all  sections  of  the  State.  It  does  not  appear  that  the 
children  outside  of  this  immediate  family  of  four  entered  the  insti- 
tution with  the  disease.  Every  proof  shows  that  they  contracted  it 
12— p.  c. 


178 

there.  Every  proof  shows,  as  far  as  it  can  be  obtained,  that  the  disease 
was  introduced  by  the  youngest  member  of  this  family  of  four,  the 
other  three  members  being  also  later  affected,  with  the  intensity  of 
the  disease  less,  in  the  older  children.  The  food  at  the  orphanage 
was  wholesome,  well  prepared  and  well  served.  The  inmates  showed 
all  evidence  of  being  well  fed.  Their  food,  in  fact,  was  equal  to  that 
of  the  average  home.  The  corn  meal  from  which  their  corn  bread 
was  made  was  procured  from  one  of  the  most  reliable  millers  of 
the  city  of  Nashville,  and  all  of  the  children  ate  the  same  quality  of 
bread.  The  same  grade  of  corn  meal  is  used  by  the  Central  Ten- 
nessee Insane  Asylum.  A  most  careful  inspection  was  made  of  that 
institution  by  Dr.  Lavinder,  Dr.  Tucker,  Dr.  Olin  West  and  myself 
and  not  a  single  case  of  pellagra  was  found  even  among  the  colored 
female  inmates. 

In  group  No.  2  it  appears  as  if  there  was  a  direct  transmission  of 
the  disease  to  the  woman  from  washing  the  clothes  of  Case  No.  7. 
The  man  had  a  well  marked  case  of  pellagra.  The  woman  did  his 
washing  during  the  winter  and  in  the  spring  developed  the  disease. 
There  seems  to  be  no  other  way  by  which  she  could  contract  it.  He 
came  into  the  community  with  the  disease.  There  was  nothing  in 
common  between  the  two,  as  far  as  we  could  learn,  except  this  wash- 
ing. On  the  face  of  the  report  of  these  two  groups,  this  disease  has 
every  appearance  among  us  of  being  infectious,  or  in  some  unknown 
way  communicable. 


DISCUSSION  ON  PAPER  OF  DR.  KING. 

Dr.  C.  H.  Lavixder,  Washington,  D.  C. :  I  do  not  like  to  let  this 
paper  pass  without  saying  a  word  or  two  in  reference  to  it.  I  visited 
Nashville  and  saw  the  situation  of  affairs  there,  and  while  I  admit 
that  Dr./  King  has  some  reason  for  the  conclusion  he  has  drawn,  I 
do  not  think,  with  regard  to  transmissibility,  that  we  should  draw  a 
general  conclusion  from  a  specific  instance  in  this  way.  While  I  do 
not  propose  to  discuss  this  matter,  I  want  in  a  friendly  way  to  offer 
my  protest  against  such  a  deduction,  so  opposed  to  the  conclusions 
and  experiences  of  all  other  students  of  the  disease. 

Dr.  W.  E.  Hibbett,  Nashville,  Tennessee :  I  do  not  rise  to  dis- 
cuss the  paper  of  Dr.  King,  but  simply  to  emphasize  some  facts. 
We  have  three  State  institutions  and  one  countv  institution  besides 


179 

the  Baptist  Hospital  in  the  immediate  vicinity  of  Nashville,  all  of 
which  have  the  same  food  supply.  In  all  the  other  institutions  the 
number  of  inmates  is  relatively  large,  running  from  four  hundred 
to  one  thousand.  In  the  Baptist  Orphanage  we  have  only  seventy- 
five  inmates.  The  disease  was  brought  in,  as  the  paper  states,  by  a 
child  brought  from  Newport,  Tennessee,  four  members  in  the  family 
having  had  the  disease,  and  one  case  after  another  developing  it  until 
there  were  seventeen  cases  in  that  institution.  After  a  most  careful 
study,  with  the  exception  of  the  group  alluded  to,  no  other  case  was 
found  in  the  vicinity  of  Nashville  or  in  any  of  the  institutions.  Now, 
with  those  facts  before  us  and  while  we  have  never  gone  on  record 
to  the  world  stating  that  pellagra  is  transmissible,  yet  what  else  can 
we  think  other  than  there  must  be  some  way  by  which  the  disease  is 
communicable  from  one  patient  to  another?  Of  course,  we  are  not 
trying  to  establish  the  infectious  nature  of  pellagra,  but  we  are  here 
to  learn  and  are  open  to  conviction. 

We  have  been  criticised  for  what  was  supposed  to  be  quarantining 
these  cases.  We  do  not  quarantine  them,  but  we  have  carried  out 
what  we  term  advisory  isolation  which  has  been  made  necessary 
because  of  the  peculiar  surroundings  of  the  cases  in  the  Baptist 
Hospital.  These  children  were_  considered  a  menace  to  the  health 
of  the  community,  and  if  they  had  been  allowed  to  remain  there, 
undoubtedly  some  violence  would  have  been  done,  and  so  at  the 
earnest  solicitation  of  the  members  of  the  Board  of  Trustees  of  the 
Baptist  Orphanage  permission  was  obtained  for  these  patients  to  be 
put  on  an  isolation  farm  where  they  are  doing  very  well. 

We  do  not  consider  that  our  water  supply  has  any  bearing  on  the 
development  of  these  cases.  At  the  Baptist  Orphanage  water 
obtained  from  a  reservoir  is  used.  The  water  supply  in  the  city 
comes  from  the  Cumberland  River. 

Dr.  Louis  Leroy,  Memphis,  Tennessee :  I  wish  to  take  the  liberty 
of  saying  a  few  words  on  this  paper.  So  far  as  amoeba  and  uncin- 
aria  are  concerned,  I  would  say  that  in  none  of  our  Tennessee  cases 
has  amoeba  or  hookworm  been  present,  and  they  have  been  sought 
for  in  each  case.  Hookworm  is  not  at  all  prevalent  with  us.  Most 
of  the  cases  in  Tennessee  come  from  the  outside.  Amoebae,  on  the 
other  hand,  are  very  prevalent.  In  the  neighborhood  of  Memphis 
we  have  an  area  in  which  amoebiasis  is  endemic.  There  is  any 
amount  of  it.  And  still  I  have  never  seen  a  case  of  amoebaisis  give 
evidence  of  pellagra,  nor  have  any  amoeboe  been  found  in  any  of  our 


i8o 

pellagrous  cases,  and  they  have  been  sought  for  diligently  in  each 
case.  As  to  the  corn  meal  which  we  get  in  Memphis,  we  get  it  from 
those  infected  districts  which  have  been  criticised,  namely,  Kansas 
City,  St.  Louis,  Chicago  and  the  North.  Almost  all  of  our  corn  meal 
comes  from  those  places. 

As  to  the  technic  of  making  blood  examinations  which  was  dis- 
cusssed  last  night  and  the  manner  of  hunting  for  leucocytosis  or  an 
increase  in  the  neutrophils,  I  have  used  a  method  which  seems  to 
avoid  piling  up  and  gives  a  better  fringe,  and  that  is,  instead  of  using 
one  slide  over  the  other  I  use  a  piece  of  cigarette  paper.  This  would 
seem  to  give  a  more  uniform  count  and  with  that  method  I  have 
found  a  slight  increase  of  twelve  per  cent,  in  the  large  mononuclears. 

With  regard  to  the  mental  symptoms  of  our  cases  of  pellagra,  the 
patients  have  not  shown  any  particular  variety.  Mostly  the  mental 
trouble  has  assumed  the  form  of  a  true  melancholia,  but  there  is  a 
mental  attitude  you  might  say  of  inanition  in  that  these  patients  get 
weaker  and  weaker,  lose  interest  in  everything  and  there  is  a  less 
desire  to  make  an  effort  to  do  anything.  They  have  not  been  morose 
or  reproaching  themselves  with  anything.  They  have  not  been 
unhappy,  but  there  has  been  greater  weakness  developing  w-ith  a 
lack  of  mental  activity. 

As  to  the  transmission  theory  of  the  disease,  I  do  not  know 
whether  Dr.  King  mentioned  the  fact  in  his  paper  or  not,  but  in  these 
Nashville  cases  we  had  one  other  remarkabk  thing  develop,  namely, 
a  nurse  w^ho  is  taking  care  of  these  cases  in  the  Baptist  Hospital  has 
developed  a  pellagrous  eruption  on  her  hands.  There  were  two  other 
cases  that  came  under  my  notice  and  these  were  school  teachers  who 
came  from  Arkansas  having  developed  the  disease  in  a  mild  form. 

Dr.  Lavinder:  Where  did  the  nurse  come  from? 

Dr.  Leroy  :  She  came  from  some  part  of  Mississippi.  She  had 
not  had  the  disease  before  she  left  there. 

I  would  like  to  make  another  suggestion  with  regard  to  the  treat- 
ment of  these  cases,  namely,  most  of  the  remedies  which  have  been 
recommended  and  given  will  act  beneficially  in  any  condition  of 
dyscrasia  or  of  malnutrition.  We  would  look  for  improvement  in 
these  cases  from  the  use  of  mercury  and  we  would  likewise  look 
for  good  from  the  use  of  arsenic,  etc. 


i8i 


THE  QUESTION  OF  THE  ETIOLOGY  OF  PELLAGRA 

J.   H.  TAYLOR,   M.   D. 

COLUKBIA^    S.     C. 

It  is  not  my  purpose,  nor  would  I  presume  for  a  moment  to  belittle 
the  remarkable  contributions  of  Lombroso  and  his  school  to  the 
study  of  this  disease,  but,  throughout  it  all,  there  is  not,  to  my  mind, 
a  satisfying  and  convincing  proof,  either  that  com  is  the  sole  factor 
in  its  production,  nor  has  it  yet  been  shown  that  a  protozoan  element 
does  not  play  a  part. 

So  dominated  has  the  Italian  thought  been  by  the  zeitoxic  theory 
of  Lombroso  that  it  comes  as  a  surprise  to  hear  even  scientists  of 
that  cotmtry  question  the  truth  of  the  sole  influence  of  spoiled  corn 
as  an  etiological  factor.  Yet  such  is  the  case,  and  we  note  that  at  the 
Third  Pellagrological  Congress,  held  at  Milan  in  September,  1906, 
"Palidino  pertinently  suggests  that  in  Mantua,  though  good  maize 
is  used,  yet  pellagra  does  not  diminish.  Mangieri  asserts  to  have 
seen  in  twelve  years  but  two  pellagrins  at  Constantinople,  where 
much  maize  is  used.  Terni  holds  that  the  etiology  is  doubtful  and  the 
real  cause  unknown.  Moreover,  he  asserts  that  in  Egypt  pellagra 
is  not  related  to  the  use  of  molded  corn,  nor  does  the  acm.e  of  the 
epidemic  correspond  to  the  Nile  flood,  which  might  cause  the 
humidity  needed  by  mold.  Ceni  described  pellagra  among  people 
who  eat  no  maize  and  emphasized  its  disappearance  upon  improv- 
ing sanitary  conditions,  the  food  remaining  the  same.  Meschinelli 
remarked  that,  in  spite  of  all  efforts,  pellagra  seem.s  to  diminish  little. 
Here  and  there  is  some  respite  in  the  advance  of  the  disease,  but  in 
general  we  cannot  say  that  the  disease  is  giving  way,  or  that  the 
number  of  the  infected  regularly  diminishes,  so  long  as  in  some 
places  it  increases.  At  best,  the  struggle  against  pellagra  but  holds 
it  in  check,  if  indeed  that.  The  results  and  the  measures  taken  are 
disappointing." 

On  the  other  hand,  in  France,  England  and  Spain,  where  the 
Lombrosian  influence  is  not  so  strong,  we  find  a  widely  spread  dis- 
satisfaction with  the  zei-toxic  claim  and  a  casting  about  for  more 
convincing  proof,  or  else  the  seeking  of  another  cause.  Notably  is 
this  the  case  with  Samson  and  Manson  in  England,  and  Nicolay  and 
Jambon  in  France,  though  Sandwith,  in  the  former  country,  ascribes 


1 82 

a  failure  to  accept  the  corn  theory  in  toto  as  evidence  of  insufficient 
study  of  the  subject. 

Following  the  incrimination  of  corn  by  Marzari  in  i8io,  every 
possible  shortcoming  has  been  laid  at  the  door  of  this  splendid  cereal, 
and  every  bacterium  and  fungus  found  growing  upon  it  has  come  in 
for  its  share  of  the  odium.  First,  it  was  a  lack  of  an  animalizing 
substance;  then  the  "Sporosorium  Maidis,"  and  one  thing  after 
another,  each,  strange  to  say,  being  stated  by  its  particular  cham- 
pion capable  of  producing  the  symptoms  in  animals.  Finally,  in 
1870,  Lombroso  put  forward  the  zei-toxic  theory,  based  upon  experi- 
mental evidence,  by  no  means  convincing,  which  deems  the  cause 
toxic  products  analogous  to  alkaloids,  developed  during  the  growth 
of  certain  molds  upon  spoiled  corn.  Neither  of  itself  is  capable  of 
producing  the  disease ;  in  fact,  the  mold  is  harmless  when  grown  on 
barley,  rye,  grapes,  jam,  etc. ;  yet  let  it  but  grow  on  spoiled  corn, 
and  there  is  developed  an  intense  poison,  capable  of  producing,  it  is 
asserted,  the  symptoms  of  a  distinct  pathological  entity,  differing  in 
every  detail  from  all  other  known  fungoid  diseases.  This  very 
uniqueness,  as  compared  with  diseases  of  a  like  origin,  is  calculated 
to  make  us  sceptical,  for  in  the  past  our  greatest  assistance  in  fore- 
casting the  nature  of  individual  diseases  has  been  by  analogy.  A 
moment's  thought  brings  to  mind  examples  of  this. 

The  lights  of  the  past  can  but  reflect  on  the  present,  and  it  would 
be  well  to  bear  in  mind  that  from  ''Sporosorium  Maidis"  Ballardini 
produced  in  man  gastritis  and  diarrhoea,  while  with  chickens  it 
caused  loss  of  weight,  droopiness  and  a  falling  of  the  feathers.  This 
he  called  pellagra.  Neusser  and  De  Glaxa  accused  the  colon  bacillus 
of  decomposing  corn,  even  sound  corn,  after  ingestion,  with  the 
production  of  a  poison  which  causes  pellagra.  The  latter  scientist 
reports  obtaining  the  characteristic  anatomical  lesions  in  dogs  fed  on 
sound  corn  porridge  and,  moreover,  the  proper  symptom.s  and 
lesions  in  animals  inoculated  with  a  toxin  produced  by  the  colon 
bacillus  cultivated  on  a  maize  medium. 

In  1894,  Pelezzi  and  Tirelli  injected  dogs  and  rabbits  and  fed  by 
mouth  toxic  substances  from  cultures  of  the  bacteria  of  maize  and 
obtained  spastic  paresis  of  the  posterial  limbs  and  other  symptoms, 
which  they  likewise  deemed  characteristic  of  pellagra. 

Similarly,  Carrarioli,  Di  Pietro,  Ceni  and  Besta  each  finds  a  differ- 
ent specific  cause  for  pellagra  and  obtains  in  animals  the  desired 
symptoms. 

Can  we  have  any  clearer  demonstration  of  the  powerful  influence 


i83 

mental  attitude  exerts  over  our  interpretations  of  physical  phe- 
nomena, notoriously  inaccurate  at  best,  and  does  it  not  tend  to  make 
us  very  cautious  about  accepting  as  final  the  statements  of  any  one 
man  or  set  of  men  about  so  fundamental  a  thing  as  the  cause  of  a 
disease  ? 

In  order  to  prove  beyond  a  reasonable  doubt  the  causative  relation- 
ship existing  between  pellagra  and  spoiled  corn,  experimental  evi- 
dence has  been  sought  for,  through  animals,  and  continues  its  role 
of  deceit,  made  possible  by  false  interpretations,  through  misdirected 
enthusiasm.  Lombroso,  especially,  has  invaded  this  field  and  pre- 
sents to  us  certain  results  that  he  considers  final.  Indeed,  I  am  told 
that  he  has  asserted  to  have  said  the  last  vv^ord  on  the  subject  twenty 
years  ago. 

Experiments^ :  First,  ten  dogs  and  a  large  number  of  chickens 
v.'ere  fed  for  six  or  eight  weeks  up  to  the  natural  end  of  life  on  com 
spoiled  with  aspergillus  and  the  following  symptoms  developed  in 
the  dogs : 

Weight :    All  the  dogs  lost  weight  except  one. 

Temperature :  There  was  nearly  always  an  elevation  of  tempera- 
ture coincident  with  the  diminution  of  weight. 

Muscular  Spasm :  A  symptom  frequent,  but  not  constant,  was  a 
tonic  muscular  spasm  and  the  increase  of  tendonous  reflexes. 

In  seven  cases  out  of  the  ten,  a  complete  torpor  of  the  muscles 
was  produced.  In  six  cases,  cerebral  torpor;  in  three,  loss  of  sensi- 
bility ;  and  in  four  cases  out  of  the  ten,  muscular  tremors. 

Diarrhoea :  The  most  frequent  complication  was  diarrhoea  pre- 
ceded by  a  refusal  of  food  and  dysphagia.  In  seven  cases,  the  latter 
symptom  was  most  often  due  to  muscular  spasm. 

Skin  :  The  erythema  of  the  skin  was  manifested  once  only  com- 
pletely and  certainly,  and  then  in  a  dog  which  remained  free  from 
anaemia,  torpor  and  spasmodic  phenomena,  and  in  which  the  sito- 
phobia  and  paresis  disappeared  with  the  appearance  of  the  erythema. 
The  microscopic  examination  of  the  skin  in  this  case  did  not,  how- 
ever, exclude  all  idea  of  a  parasitic  cause. 

In  twelve  chickens  fed  on  spoiled  corn  convulsive  phenomena 
were  exceptionally  noted  and  there  were  produced  only  atrophy  of 
the  feather  follicles  with  changes  of  the  skin  and  horny  append- 
ages. 

Finally,  the  experiment  that  in  the  opinion  of  the  Lombrosians 
goes  farthest  towards  definitely  proving  their  contention  was  that 
made  in  the  case  of  human  beings.     The  tincture  of  corn  spoiled  by 


1 84 


penicillium  glaucum  was  given  for  a  length  of  time  to  twelve  sound 
and  healthy  individuals,  soldiers  and  laborers  at  work  in  the  city, 
and,  at  the  time  of  the  experiment,  well-fed.  The  following  results 
were  obtained : 


Symptoms. 

Bulimia 

Pruritus  of  back  and  face 

Loss  of  weight 

Urine  diminished  and  of  high  specific  gravity 

Diarrhoea 

Diurnal  Somnolence 

Eructations 

Persistent  muscular  weakness 

Desquamations 

Headaches 

Anorexia 

Burning  of  the  eyelids 

Repugnance  for  water 

Hyperidrosis 

Ephelides  on  the  arms  and  hands ' 

Palpitation  of  the  heart 

Syncope 

Variation  of  the  pulse 

Increase  in  weight 

Intense  thirst 

Increase  of  muscular  force 

Sensation  of  heat  in  the  head 

Sensation  of  warm  water  on  the  back.  .    .  . 

Irritability  and  emotionalism 

Restlessness  at  night 

Erythemas 

Tinnitus  aurium 

Redness  and  burning  of  the  skin 

Burning  of  scrotum 

Mydriasis 

Ptosis 

Prickling  sensation ; 

Oppression  and  Precordial  pains 

Vertigo 

Furunculosis.  .   T 


Number  of  Cases. 
..   ..        9 


i85 

Enteralgia I 

Sensation  of  foreign  body  in  the  head i 

Salty  taste i 

Burning  in  the  throat i 

Xo  symptoms 2 

In  these  experiments  we  note  at  once  an  utter  lack  of  uniformity 
in  the  symptoms  presented  by  the  different  individuals,  and,  indeed, 
in  some  there  were  no  symptoms  at  all.  Now,  can  one  accept  these 
phenomena  of  acute  intoxication  as  definite  proof  that  corn  spoiled 
by  penicillium  and  asperigillus  produces  pellagra,  a  disease  charac- 
teristic only  in  its  entire  symptom  complex?  One  of  the  most  strik- 
ing elements  of  the  disease,  a  symmetrical  skin  lesion,  is  entirely 
wanting,  and,  moreover,  would  it  not  be  desirable,  if  we  are  to  accept 
as  positive  evidence,  that  the  eruptions  really  occurring  should 
tend  to  show  some  slight  periodicity,  a  glaring  characteristic  of  the 
true  disease? 

Pellagrosine,  the  essential  poison  of  Lombroso,  will  produce  in 
dogs  and  chickens  but  droopiness  and  diarrhoea  and  in  man  torpor, 
anorexia,  nausea  and  diarrhoea.  Would  it  not  be  reasonable  to 
expect  something  more  classic  than  this  ? 

We  would  not  pretend  to  deny  that  these  experiments  show  a 
development  of  a  powerful  toxine,  that  affects  most  unhappily  the 
victims  subjected  to  its  influence,  but,  on  the  other  hand,  animals 
can  be  made  to  develop  diarrhoea  and  succumb  by  being  fed  on  any 
kind  of  mold  and  the  symptoms  produced  in  Lombroso's  experiments 
can  be  reproduced  with  extracts  from  spoiled  and  moldy  wheat  and 
barley.  Ciotto  has  even  succeeded  in  demonstrating  the  presence  of 
alkaloid  substances  both  in  unaltered  corn  and  in  other  cereals. 
Furthermore,  Babes  and  Sion^  state  that  amygdalin  causes  appear- 
ances similar  to  pellagra  in  plant-eating  animals,  yet  is  inert  in  car- 
nivora,  and,  moreover,  they  state  that  the  following  symptoms  have 
been  produced  in  mice,  rabbits  and  dogs  by  other  toxines  than  that 
of  spoiled  maize,  viz. :  loss  of  appetite,  diarrhoea,  inflammation  of  the 
bowels  wdth  hemmorrhage  and  general  weakness ;  paralysis,  begin- 
ning at  the  hind  extremities,  tetanus  and  clomus-like  cramps ;  opis- 
thotonus ;  skin  affections  and  particularly,  also,  desquamations  and 
falling  of  the  hair. 

We  admit  it  is  not  possible  to  deny  the  overwhelming  evidence  of 
the  frequent  and  very  suggestive  association  of  pellagra  with  the 
ingestion  of  corn,  and  especially  of  spoiled  corn.     Indeed,  these  may 


i86 

contain  very  essential  elements  in  the  production  of  the  disease,  but 
this  is  far  from  naming  them  as  the  ultimate  and  essential  element 
in  its  production. 

Aside  from  the  bare  experimental  phase  of  the  question,  certain 
discrepancies  in  the  maize  theory  are  v/orthy  of  our  close  scrutiny. 
The  cultivation  and  extensive  use  of  maize  antedates  by  about  200 
years  the  appearance  of  pellagra  in  Italy,  and  zeists  explain  the  long 
years  of  freedom  from  symptoms  in  the  individual  by  asserting  that 
the  poison  acts  very  slowly,  taking  these  years  to  produce  the  disease 
in  man,  yet,  when  a  guinea  pig  or  other  animal  is  killed  within  a 
few  short  days  by  the  identical  poison,  so  stated,  it  is  still  accused 
of  dying  of  pellagra. 

There  are  extensive  regions  today  where  pellagra  is  widespread, 
but  where  corn  is  nf^ither  grown  nor  eaten.  This  is  notably  the  case 
as  cited  by  Pons  Sanj^  in  the  province  of  Vodjoz,  Spain,  where 
pellagra  is  endemic,  though  the  inhabitants  eat  no  maize ;  and,  again, 
the  province  of  Ovido  was  once  ravaged  by  pellagra,  but  in  1900  it 
suffered  least,  though  no  changes  had  taken  place  in  the  culture, 
storage,  preparation  or  quantity  eaten  of  maize,  while  the  province 
of  Madrid,  where  maize  is  only  seldom  used  as  food,  suffered 
severely. 

Now,  what  are  we  to  say  about  those  cases  of  pseudo-pellagra, 
so-called,  and  sporadic  pellagra,  reported  as  far  back  as  1852  and 
more  recently  in  France  as  developing  in  persons  who  had  never 
eaten  the  products  of  corn  ?  Most  of  the  French  cases  are  admittedly 
alcoholic,  but  we  cannot  ascribe  their  origin  to  alcohol  alone,  and 
we  find  ourselves  still  face  to  face  with  an  unknown  causive  agent, 
just  as  we  are,  in  the  ultimate  analysis,  in  cases  of  true  pellagra. 

In  1903,  Garbini  identified  several  cases  of  undoubted  pellagra  at 
the  Messina  asylum,  in  natives  of  Cicily,  where  maize  is  not  culti- 
vated, and,  what  is  more  to  the  point,  they  had  been  inmates  of  the 
institution  for  a  long  time  and  had  certainly  eaten  no  maize  for 
several  years  prior  to  the  appearance  of  their  erythema. 

In  Jamaica,*  it  is  reported  that  insane  patients  who  had  been 
shut  off  absolutely  from  a  corn  ration  for  the  period  of  a  year  had 
developed  pellagra.  Can  these  instances  be  satisfactorily  accounted 
for  by  the  Lombrosians  ? 

Again,  is  there  adequate  explanation  for  only  20,000  cases  of 
pellagra  among  five  million  Roumanian  peasants  in  1898,  as  reported 
by  Babes  and  Sion,  and  for  the  few  hundreds  at  present  among  our 
own  millions?    Certainly,  in  Roumania  the  status  of  corn  culture  and 


i87 

preparation  has  not  changed  in  a  great  many  years  as  is  held  up 
against  our  country,  or,  if  change  has  taken  place  in  Roumania,  it 
has  been  for  the  better,  in  the  light  of  the  Zeist  propaganda.  The 
Zeist  explains  this  by  predisposition  in  the  individual,  yet  it  seems 
hardly  probable  that  neighboring  peoples  would  show  such  marked 
variations  in  susceptibility.  Of  course,  we  still  have  that  indefinite 
and  uncertain  factor,  hereditary  pellagra — atavistic  pellagra,  as  Lom- 
broso  would  have  it — found  developing  in  grandchildren  of  recog- 
nized pellagrins,  but  here  it  seems  to  me  we  are  again  facing  our 
unknown  etiological  factor.  Is  this,  indeed,  transmitted  suscepti- 
bility to  the  poison  of  spoiled  corn  ?  Why  should  certain  individuals 
of  the  same  inheritances,  the  same  household  and  living  under  identi- 
cal food  conditions,  be  attacked  and  the  others  remain  free  of  symp- 
toms? And,  again,  why  should  persons  of  the  rural  districts,  and 
rarely  those  in  towns,  be  attacked,  though  both  use  maize  as  a  staple 
article  of  diet?  The  Zeists  explain  this  last  contention  by  claiming 
that  the  best  corn  is  sent  to  the  city  and  the  poorer  quality  eaten 
by  the  country  peasants ;  but  this  seems  not  to  explain  the  phenomena 
enirely  to  our  satisfaction,  for  surely  much  corn  must  spoil  in  stor- 
ing. And,  moreover,  statistical  data  of  Lombroso  himself  and  of 
Babes  and  Sion  show  that  scarcely  25  per  cent,  of  pellagrins  can  be 
shown  to  be  in  the  habit  of  eating  spoiled  corn.  Again  we  face  an 
unknown  element. 

In  considering  the  glaring  incongruities  of  the  maize  theory  of 
pellagra,  the  striking  and  distinct  periodical  appearance  of  the  skin 
symptoms,  a  phenomena  incompatible  with  toxine  poison  of  the 
maize  type,  and  its  striking  similarity  to  certain  diseases  of  a  proto- 
zoan origin,  Sambon^  has  mentioned  as  possible  a  similar  etiology 
for  it.  This  suggestiveness  runs  throughout  the  entire  symptomat- 
ology, pathology  and  treatment  of  both  syphilis  and  sleeping  sick- 
ness, or  trypanosomiasis,  both  protozoan  diseases,  and  the  Wasser- 
man  reaction  justifying  us  in  considering  general  paresis  and  tabes 
dorsilis  as  syphilitic  manifestations,  we  include  these  under  this 
head  : 

Type:  They  are  all  essentially  slow  progressive  toxaemias,  the 
duration  of  pellagra  being  from  a  few  weeks  to  twenty  or  more 
years ;  that  of  sleeping,  sickness  from  three  months  to  three  years ; 
and  syphilis  from  a  few  months  in  the  malignant  type  to  an  indefinite 
period. 

Remissions :  In  each  we  may  have  definite  and  distinct  remissions, 
lasting  from  a  few  weeks  to  months  or  years  in  syphilis;  from  one 


i88 

spring  to  the  next  in  pellagra;  and  in  sleeping  sickness,  before  the 
final  stage,  we  have  short  but  distinct  exacerbations  and  remissions. 

Symptomatic  Similarity  :  In  all  we  have  the  prodromes  of  general 
malaise,  headache,  languor  and  mild  digestive  disturbances,  which 
clinical  symptoms  are  exhibited  by  all  diseases  of  a  microbe  nature, 
and  are  readily  explained  by  the  theory  of  intoxications  by 
ptomaines  engendered  by  the  organisms  which,  as  they  become 
more  generalized,  will  produce  more  pronounced  symptoms.  A  rise 
in  temperature  is  constant  in  sleeping  sickness,  usual  in  syphilis-  and 
occasional  in  pellagra. 

Skin :  A  salient  feature  of  each  is  a  striking  skin  eruption,  char- 
acteristic and  practically  constant,  due,  in  all  probability,  to  a  local- 
ized deposit  of  virus,  with  resulting  changes  in  the  texture  and 
appearance  of  the  involved  areas.  In  pellagra  and  syphilis,  this 
lesion  is  a  symmetrical,  while  in  sleeping  sickness  there  is  no  definite 
arrangement.  In  pellagra  it  appears  usually  on  exposed  surfaces; 
in  sleeping  sickness  and  syphilis  it  may  be  general  over  the  body  and 
limbs.  In  pellagra  it  appears  first  as  an  erythema,  later  taking  on 
a  pigmented,  scaly  character,  as  usually  seen,  and  is  often  pruritic. 
In  sleeping  sickness  a  peculiar  itchy  eruption  is  an  early  manifesta- 
tion, and  appears  as  an  ill  i  defined  erythema  in  patches  distinctly 
ringed,  in  some  cases  seven  to  eight  inches  in  diameter.  Again,  it 
may  appear  as  rubelloid  spots  of  congestion,  shading  off  gradually 
into  normal  skin,  and  finally  it  may  present  as  measly  patches  with 
the  skin  appearing  slightly  thickened  and  swollen.  The  skin  mani- 
festations of  syphilis  are,  of  course,  legion,  and  the  appearances  of 
both  sleeping  sickness  and  pellagra  may  be  simulated  exactly. 

General  Symptoms  :  In  the  three  there  is  common  to  each  that 
gradual  tendency  to  weakness,  emphasized  especially  in  the  lower 
limbs  in  pellagra  and  general  paresis,  accompanied  by  progressive 
anemia  and  emaciation. 

Nervous  Symptoms :  We  come  now  to  possibly  the  most  remark- 
able of  all  the  similarities ;  namely,  that  of  the  nervous  symptoms  in 
pellagra  and  general  paresis.  In  that  type  of  pellagra  where  the 
spinal  and  mental  symptoms  stand  forth  prominently  we  have  the 
picture  of  general  paresis  so  closely  simulated  in  every  respect  that 
it  is  extremely  difficult  to  differentiate  the  two  with  the  nervous 
symptoms  alone  considered.  The  one  point  of  difference  that  has 
been  called  attention  to  is  the  absence  of  motor  speech  derange- 
ments in  pellagra,  which  is  a  constant  symptom  of  general  paresis. 
Tuczek,  indeed,  claims  that  the  conditions  undoubtedly  do  coalesce, 


i89 

beginning  with  pellagroid  symptoms  and  finally  becoming  true  gen- 
eral paresis.  As  a  rule,  the  nervous  symptoms  in  pellagra  are  not 
progressive,  while  in  general  paresis  they  are  essentially  so.  In 
sleeping  sickness  we  have  the  same  headache  and  mental  hebetude, 
the  patient  appearing  apathetic,  with  cerebration  retarded ;  muscular 
spasms,  epileptic  seizures  and  tremors  often  appear,  paretic  symp- 
toms in  general  gradually  supervening.  The  deeper  reflexes  are 
primarily  exaggerated,  followed  by  a  total  loss ;  later,  contractions  of 
the  flexors  of  the  arms  and  legs  appear  and  rigidity  of  certain  groups 
of  muscles  is  usual.  The  mental  state,  according  to  Jackson,  is  not 
usually  that  of  general  paresis,  mania  and  the  delirium  of  exaltation 
rarely  being  observed,  while,  on  the  contrary,  despondence  and  a  con- 
sciousness of  wretchedness  is  the  rule.  In  other  respects  it  resembles 
general  paresis. 

Pathology :  Here  we  have  further  verification  of  the  relationship 
between  syphilis  and  pellagra  in  the  spinal  cord  changes.  Lombroso 
states  that  in  the  most  typical  cases  they  suggest  that  in  incipient 
tabes,  with  this  difference :  while  in  pellagra  few  changes  are  found 
below  the  dorsal  region,  in  tabes  the  lumbar  region  is  chiefly  affected, 
though  the  cervical  may  be  most  involved.  Both  show  degenerative 
changes  in  definite  portions  of  the  spinal  cord,  tabes  attacking  the 
posterior  columns  especially  and  pellagra  the  lateral  or  both  posterior 
and  lateral.  Both  diseases  show  a  combination  sclerosis.  Marie  con- 
siders that  this  sclerosis  of  pellagra  resembles  more  closely  that  of 
general  paresis  than  tabes — both,  you  will  observe,  being  syphilitic 
lesions.  CEdema  of  the  central  nervous  system  and  a  chronic  lepto- 
meningitis is  common  to  general  paresis  and  pellagra,  while  in 
sleeping  sickness  we  have  a  universal  meningo-encephalitis  in  the 
form  of  a  small  round-cell  infiltration. 

Treatment :  Professor  Neisser,  of  Breslau,  has  reported  his  experi- 
ments with  syphilis  on  apes  in  Java,  where  he  demonstrated  the  extra- 
ordinary influence  of  an  arsenical  preparation,  atoxyl,  on  affected 
animals.  It  acts  as  a  true  specific  and  prevents  the  development  of  the 
spirochetes,  so  that  when  given  early  the  disease  is  stopped  com- 
pletely, and  the  animal  can  later  be  re-infected.  From  this  drug 
alone  has  benefit  been  received  in  the  case  of  sleeping  sickness.  While 
this  particular  form  of  arsenic  has  proven  a  disappointment  with  us 
in  pellagra,  yet,  Fowler's  solution  of  arsenic  seems  to  hold  out  the 
greatest  amount  of  relief  in  cases  taken  in  the  early  stages.  On  the 
other  hand,  Lombroso  himself  has  spoken  of  splendid  results  from 
atoxyl,  while  Babes  and  others  report  brilliant  results  from  a  com- 


190 

bination  of  it  with  arsenic  trioxide.®  Thus  we  see  arsenic  alone 
giving  relief  in  two  of  the  three  diseases  and  acting  as  a  specific  in  the 
third.  In  this  connection,  while  pointing  out  the  similarities  between 
pellagra  and  other  protozoan  diseases,  there  is  food  for  thought  in 
the  striking  influences  of  light  on  the  skin  lesions  of  pellagra  and 
smallpox — another  protozoan  disease — as  also  is  the  fact  that  there 
has  been  noted  in  the  past  and  Lavinder  finds  it  in  the  cases  exam- 
ined here,  a  constant  relative  increase  in  the  monocular  cells  of  the 
blood,  a  phenomenon  likewise  characteristic  of  syphilis,  sleeping  sick- 
ness, smallpox  and  protozoan  diseases  in  general. 

Finally,  regarding  the  pathogenic  protozoa  in  man,  we  have  but 
little  more  than  lifted  the  edge  of  the  veil,  but  even  that  opens  to  us  a 
boundless  horizon.  With  the  exception  of  the  malarial  organism,  the 
complete  life  history  of  not  one  protozoa  causing  disease  in  man  is 
known.  Of  the  others,  we  know  only  disconnected  portions  of  life 
cycles  that  may,  and  probably  have,  many  varying  forms.  We  do 
know,  however,  that  the  majority  of  identified  forms  are  restricted 
to  a  particular  organ  or  tissue,  as  the  malarial  parasite  and  the  try- 
panosome  and  others  to  the  blood ;  the  organisms  of  scarlet  fever  and 
smallpox  to  the  skin ;  some  to  epithelial  cells ;  some  to  cell  nuclei  and 
others  to  muscle  cells.  Because  we  find  nothing  suggestive  of  pro- 
tozoan life  in  the  blood  and  other  organs,  so  far  examined,  of  pella- 
grins, it  does  not  argue  that  we  shall  not  eventually  find,  with  fuller 
knowledge  of  this  form  of  life,  the  real  organism  tucked  away  in 
some  obscure  recess  of  the  body.  However,  it  is  an  interesting  fact 
that  in  some  forms  of  protozoa  there  are  formed  under  certain  condi- 
tions protective  cysts  within  which  the  living  cells  lie  quiescent  for 
varying  periods,  until  environmental  conditions  are  favorable  to  liber- 
ation and  renewed  activity.  We  note  especially  this  quiescence  in  the 
malarial  organisms,  which  may  remain  latent  for  many  years  in  the 
blood  and  by  changes  in  the  density  of  the  surrounding  medium  or 
through  some  minute  change  in  the  composition  of  the  host's  blood, 
be  stimulated  to  renewed  activity.  We  are  all  familiar  with  the  latent 
periods  which  are  characteristic  of  syphilis.  In  the  case  of  pellagra 
there  is  irresistibly  borne  in  upon  us  some  as  yet  intangible  relation- 
ship between  corn,  especially  spoiled  corn,  and  the  development  of 
the  disease.  Now,  knowing  what  we  do  of  the  quiescent  phases  of 
certain  protozoa  and  the  stimuli  necessary  to  their  renewed  activity, 
is  it  not  possible  that,  either  one  cycle  of  an  organism  causing  pella- 
gra, if  there  be  such,  finds  its  habitat  in  corn,  or  else  may  it  not  lie  in 
the  tissues  somewhere,  possibly  the  intestinal  tract,  and  the  ingestion 


191 

of  corn,  producing  the  chemical  stimulus  necessary  to  its  develop- 
ment, there  results  an  invasion  of  the  host  with  a  development  of  the 
usual  symptoms  ?  It  seems  to  me  this  would  account  for  the  recrudes- 
cences following  the  eating  of  corn  products,  and  also  we  might  rea- 
sonably stretch  the  analogy  to  include  those  cases  developing  sporadi- 
cally or  pseudo-pellagra,  accounting  for  these  by  the  ingestion  of 
some  other  product  than  corn,  producing  a  like  stimulus,  but  much 
more  seldom  eaten  than  corn. 


REFERENCES  AND  BIBLIOGRAPHY. 

^Pellagra,  by  A.  Marie,  Paris.  Authorized  Translation  by  Dr.  J.  W.  Babcock, 
of  Columbia,  S.  C,  and  C.  H.  Lavinder,  of  U.  S.  P.  H.  and  M.  H.  S.,  1909. 

^Pellagra,  Babes  and  Sion,   1901. 

sThe  Diseases  of  Warm  Countries,  B.  Scheube,  1902. 

^''Pellagra  in  Jamaica,"   D.   J.   Williams,  M.   D.,   1909. 

"Sambon — British  Medical  Journal,  1905,  II. 

•Notes  on  the  Prognosis  and  Treatment  of  Pellagra,  C.  H.  Lavinder,  1909. 

Various  Textbooks,  including'  especially  Tropical  Diseases,  Manson,  Lec- 
tures on  Tropical  Diseases,  Manson,  Osier's  Modern  Medicine. 


DISCUSSION  ON  THE  PAPER  OF  DR.  TAYLOR 

Dr.  William  Allen,  Charlotte,  North  Carolina:  Dr.  Taylor,  in 
his  paper,  drew  an  analogy  between  the  treatment  of  syphilis  and 
pellagra.  I  have  had  several  cases  of  pellagra  that  gave  a  past  his- 
tory of  syphilis.  They  were  first  put  on  the  treatment  recommended 
by  Babes  last  winter,  which  failed  absolutely  to  bring  about  any 
improvement.  Later  they  were  put  on  hypodermic  injections  of 
salicylate  of  mercury  and  recovered.  It  is  rather  suggestive  that 
the  cases  which  gave  a  history  of  syphilis  should  recover  under  the 
use  of  mercury.  Now,  I  am  trying  hypodermic  injections  of  a  com- 
bination of  mercury  with  arsenic,  the  cacodylate  of  mercury.  I  would 
like  to  ask  Dr.  Taylor  whether  he  has  ever  tried  mercury  in  any 
of  his  cases  either  with  or  without  a  history  of  syphilis  ? 

Dr.  Walter  H.  Buhlig,  Chicago,  Illinois :  Along  the  line  of  the 
etiology  of  pellagra,  I  wish  to  mention  the  results  of  a  few  experi- 
ments we  have  made  at  the  Peoria  State  Hospital  for  the  Insane, 
under  the  auspices  of  the  Illinois  St^te  Board  of  Health. 

First,  with  reference  to  amoebae.  I  should  have  covered  this  phase 
of  the  subject  yesterday,  but  we  were  so  pushed  for  time  that  I  did 
not  mention  what  we  had  done.  Dr.  Nichols  and  Dr.  Siler  told  you 
in  their  joint  paper  yesterday  of  finding  amoebae.     As  we  were  on 


192 

the  ground  we  knew  they  found  them.  The  water  was  examined  by 
us  and  amoebae  were  found  in  it.  A  Httle  later,  in  the  middle  of 
October,  I  sent  an  assistant  for  more  water  and  got  the  following 
samples :  The  city  water  in  Peoria ;  the  city  water  of  Peoria  at  the 
institution  which  corresponded  to  the  water  examined  in  the  first 
experiments;  the  well  water  of  the  institution;  and  some  water 
which  came  from  the  refrigerating  plant  and  which  flowed  into  the 
large  tank  which  furnished  water  for  the  institution.  We  found 
no  amoeba;  in  the  city  water  of  Peoria.  We  found  none  in  the  city 
water  taken  at  the  institution,  contrasting  this  with  our  previous 
experiments  in  which  we  did  find  them.  In  the  well  water  no 
amoebae  were  found,  but  in  the  water  which  came  from  the  refriger- 
ating plant  we  found  amoebae  in  large  numbers.  We  could  not 
understand  the  disparity  in  the  findings  in  the  city  water  in  the 
earliest  and  this  last  examination.  So  I  wrote  to  Dr.  Zeller  and 
asked  him  whether  this  tank  had  been  cleaned  out,  and  he  told  me 
that  about  the  ist  of  October  they  cleaned  and  steamed  it.  That 
probably  accounted  for  the  absence  in  the  last  experiment  of  the 
amoebae  in  the  city  water  at  institution ;  but  the  pipes  of  the  refriger- 
ating plant  had  not  been  cleaned  out  and  the  water  coming  from 
them  still  contained  amoebae. 

With  this  as  a  clue,  I  examined  the  water  at  our  school,  the  North- 
western University  Medical  School,  where  somewhat  similar  condi- 
tions obtain.  We  get  our  water  from  Lake  Michigan,  and  it  is  sup- 
plied to  us  in  two  ways.  The  water  comes  direct  from  the  mains 
on  some  of  the  floors,  but  on  the  upper  floors  the  water  is  supplied 
by  means  of  a-  large  tank  on  the  roof,  to  which  water  is  pumped 
from  the  basement.  In  the  water  from  the  mains  direct  there  are  no 
amoebae,  but  a  great  many  flagellates,  and  in  the  water  from  the 
tank  I  found  large  quantities  of  amoebae  as  well  as  flagellates.  These 
experiments  have  a  distinct  bearing  on  the  question  of  the  patho- 
genicity of  the  amoebae  found  in  the  water  and  the  stools  at  the 
Peoria  State  Hospital. 

We  have  also  gone  into  the  question  of  the  bacteriology  of  the 
stomatitis  of  pellagra.  In  direct  smears  we  found  a  large  number  of 
spindle  shaped  bacilli  and  spirochetes  of  the  Vincent's  angina  type. 
In  addition  we  saw  a  good  many,  bacilli  of  the  bacillus  aerogens  cap- 
sulatus  type  and  some  large  cocci  that  are  much  like  the  large  diplo- 
cocci  found  in  the  stools  of  normal  individuals.  Culturally  we  found 
practically  always  gram  negative  bacilli  of  colon  morphology,  and 
after  plating  what  we  thought  confidently  were  colon  bacilli  proved 


193 

to  be  two  organisms,  one  that  stimulated  the  bacillus  lactis  serogenes 
and  the  other  one  that  had  all  of  the  characteristics  of  the  bacillus 
cloacae. 

Capt.  H.  J.  Nichols,  U.  S.  Army :  I  have  been  very  much  inter- 
ested in  listening  to  Dr.  Taylor's  paper,  and,  as  I  said  yesterday, 
the  parasitic  theory  of  any  disease  is  the  most  attractive  one,  but  I 
do  not  feel  that  we  are  safe  in  following  in  Dr.  Taylor's  lead  on  this 
proposition. 

We  have  had  the  same  experience  with  beri-beri.  This  disease 
in  the  tropics  has  been  a  great  problem  for  many  years.  At  first, 
it  was  thought  that  rice  was  the  cause  of  the  disease;  then  opinion 
swung  over  in  favor  of  a  protozoan  or  bacterium,  but  finally  it  has 
come  back  to  rice  again,  and  unquestionably,  there  is  some  definite 
connection  between  white  rice  and  beri-beri,  although  the  exact 
relation  is  still  unknown.  We  are  now  going  through  the  same 
phases  in  this  disease. 

First,  every  one  was  pretty  well  satisfied  that  it  had  something  to 
do  with  the  diet ;  now  theories  are  being  urged  in  favor  of  a  protozoal 
or  bacterial  origin  of  the  disease.  It  seems  to  me  that  this  is  largely 
a  psychological  reaction,  rather  than  a  reaction  based  on  reliable 
data.  Dr.  Sambon  has  made  quite  a  stir  in  medicine  on  account  of 
his  free  lance  methods  of  theorizing  about  dififerent  diseases.  For 
instance,  black  water  fever,  which  men  in  India  feel  sure  is  con- 
nected definitely  with  malaria,  is  attributed  by  Sambon  to  some 
special  organism.  It  is  the  same  way  in  regard  to  pellagra.  These 
theories  have  a  psychological  basis  rather  than  one  founded  on  actual 
data.  So  far  as  our  position  is  concerned,  it  should  be  a  conservative 
one,  and  we  should  take  the  ground  that  as  far  as  we  can  tell  a  corn 
diet  has  some  definite  connection  with  pellagra,  and  that  in  our 
prophylaxis  we  must  cut  out  this  article  of  diet  among  predisposed 
persons.  Until  further  studies  are  made  we  are  not  justified  in 
going  into  the  air  for  any  hypothetical  protozoal  or  bacterial  origin 
of  this  disease. 

Dr.  J.  J.  Watson,  Columbia,  South  Carolina :  I  wish  to  express 
some  sentiment  in  regard  to  this  subject.  I  do  not  think  we  should 
let  the  ideas  of  any  one  man  or  any  set  of  men  disturb  us  or  carry 
us  away  from  the  real  truth.  Many  arguments  are  advanced  con- 
cerning the  probable  protozoic  origin  of  pellagra,  and  that  the  drugs 
that  are  used  in  the  treatment  of  protozoic  diseases  are  beneficial  or 

13— p.  c. 


194 

curative  in  cases  of  pellagra.  But  I  want  to  say  that  there  is  no 
drug  which  cures  pellagra.  I  have  had  extensive  experience  with 
this  disease,  and  I  have  seen  no  drug  that  would  cure  it.  Arsenic 
does  not  do  it.  I  have  had  patients  recover  when  I  gave  them  mor- 
phine. Yet,  on  the  other  hand,  I  have  had  others  recover  when  I 
gave  them  nothing,  and  when  I  got  out  of  the  way  they  got  well. 
So  the  argument  that  such  and  such  a  drug  which  is  used  in  pro- 
tozoal diseases  beneficially  does  not  hold  here.  1  am  familiar  with 
Dr.  Sambon's  theory  as  to  the  protozoal  nature  of  pellagra;  but  I 
want  to  say  in  this  connection  that  ordinary  good  corn  does  not 
produce  pellagra.  It  is  when  corn  is  damaged  that  we  get  pellagra. 
That  is  the  experience  of  those  men  who  are  dealing  with  this  disease 
and  who  have  studied  it  closely  for  generations,  and  we  cannot 
afford  to  pass  the  observations  of  those  men  of  vast  experience  over 
lightly.  The  trouble  is  not  with  corn.  God  Almighty  in  his  infinite 
wisdom  has  given  us  a  climate  where  we  can  mature  and  cure  corn, 
but  in  Italy  it  is  entirely  different.  There  they  have  an  artificial  way 
of  drying  corn.  They  cannot  leave  it  in  the  fields  until  it  is  matured, 
and  until  the  excessive  moisture  is  evaporated  by  the  glorious  orb  of 
day.  The  trouble  is  in  the  way  we  handle  corn,  and  not  in  the  corn 
itself. 

Dr.  Hiram  Byrd_,  Jacksonville,  Florida :  Those  of  us  who  live  in 
the  South  in  the  yellow  fever  territory,  and  who  have  had  occasion  to 
look  over  the  literature  on  yellow  fever,  will  recall  very  vividly  that 
twenty  years  ago,  yes,  ten  years  ago,  it  was  thought  that  yellow 
fever  was  transmitted  by  fomites.  It  is  true,  here  and  there  was 
a  dissenter,  some  eccentric  somebody  who  did  not  accept  the  theory, 
but  we  nevertheless  believed  that  yellow  fever  was  transmitted  by 
fomites.  We  had  to  apologize  for  a  number  of  things  in  order  to 
live  up  to  that  theory.  But  we  apologized  and  accepted  the  theory 
and  went  upon  the  assumption  that  yellow  fever  was  transmitted  in 
that  way.  Today,  when  we  come  to  make  assertions,  our  friends 
say  to  us,  what  about  yellow  fever?  We  have  had  to  take  back 
water.  We  all  know  that.  The  one  thing  that  impresses  itself  upon 
us  with  regard  to  pellagra  is  that  we  do  not  know  its  cause.  Let  us 
not  put  ourselves  on  record  prematurely.  Now,  if  there  is  any  one 
thing  that  this  conference  has  forced  upon  me,  it  is  the  belief  that 
we  do  not  know  the  etiology  of  pellagra ;  that  we  are  today  in  the 
dark.  This  conference  has  taken  upon  itself  the  character  of  an 
international  body.     Every  part  of  the  world,  where  pellagra  is  an 


195 

important  problem,  is  represented  here  either  in  person  or  in  senti- 
ment. The  proceedings  of  this  conference  will  be  read  by  the  entire 
world,  and  is  it  a  safe  thing,  in  the  present  state  of  our  knowledge, 
for  us  to  put  ourselves  on  record  that  corn  is  the  cause  of  pellagra? 
I  contend  that  it  is  not.  We  had  better  say,  we  do  not  know.  This 
is  a  scientific  body.  It  ought  not  to  accept  anything  short  of  absolute 
proof  which  the  most  exact  science  can  furnish.  So  far  as  corn  is 
concerned,  the  least  we  can  say  is,  it  is  unproven  that  it  is  the  cause 
of  this  disease,  and  let  us  not  put  ourselves  in  the  humiliating  posi- 
tion at  some  future  time  of  having  to  take  back  what  we  may  say  in 
this  conference.     (Applause.) 

Dr.  W.  H.  Dial,  Laurens,  South  Carolina:  While  I  am  a  phy- 
sician, I  was  raised  on  a  farm  and  am  still  interested  in  farming. 
We  all  know  that  sound,  properly  cured  corn  is  one  of  the  greatest 
and  best  of  our  food  products.  But  the  way  of  harvesting  in  these 
later  years  has  had  something,  no  doubt,  to  do  with  damaged  meal. 
We  now  cut  the  stalks  from  the  ground  before  the  corn  is  ripe,  tie 
them  in  bundles,  and  stack  them  in  great  shocks,  to  thus  mature  in 
the  fields,  claiming  that  the  stalk  holds  or  retains  enough  nourish- 
ment to  properly  mature  the  grain. 

This  is  different  from  the  old  way  of  stripping  the  blades  from 
the  stalk  and  allowing  the  corn  to  mature  on  the  stalk  still  growing 
in  the  ground  before  gathering  or  harvesting.  May  this  difference 
in  the  maturing  of  the  corn  not  have  something  to  do  with  damaged 
corn  and  meal?  And  damaged  meal,  we  are  told,  produces  pellagra. 
This  late  way  of  maturing  corn  should  be  thoroughly  investigated. 

Dr.  J.  D.  Jones,  Sweet  Water,  Alabama:  I  hail  from  the  great 
old  State  of  Alabama,  near  the  City  of  Mobile,  and  have  had  consid- 
erable experience  during  the  last  three  years  in  treating  pellagra.  X 
have  now  under  my  observation  twenty  cases  of  pellagra,  mostly  in 
the  country  district.  This  disease  has  been  under  my  observation 
for  three  years.  For  a  year  and  a  half  I  did  not  know  what  it  was, 
but  by  the  aid  of  Dr.  Searcy  of  our  State  Insane  Hospital,  I  was  led 
into  the  light  to  know  what  it  was.  I  have  had  during  that  time 
three  deaths.  I  have  now  under  my  treatment  three  patients  who  are 
insane.  When  I  left  home  one  of  them  was  nearly  dead,  and  may 
be  dead  before  I  get  home.  I  am  also  engaged  in  the  mercantile 
business.  Three  years  ago,  if  you  remember,  in  October  of  1906, 
about  the  loth,  we  had  a  killing  frost  which  reached  from  the  North 


196 

to  the  South,  even  to  Alabama,  and  by  reading  the  papers  you  found 
it  was  plainly  stated  that  the  corn  fields  of  Kansas  and  of  the  middle 
West  and  North  were  blackened  by  that  frost;  that  corn  was  not 
matured  when  the  frost  came.  And  the  next  spring  we  had  consid- 
erable wet  weather,  so  that  it  was  impossible  for  the  merchants  of 
my  section  to  procure  sound  corn  for  their  patrons.  The  corn  meal 
at  that  time  was  cheaper  on  the  market  than  pure  corn,  and  that  is 
always  the  case  in  the  mercantile  world.  You  will  find  a  bushel  of 
damaged  meal  can  be  bought  cheaper  in  such  a  time  than  a  bushel  of 
pure  corn.  I  could  not  secure  more  than  enough  corn  to  supply  the 
demand  of  my  customers  for  more  than  ten  days  at  the  time  because 
the  corn  would  become  damaged,  and  I  could  not  sell  it.  I  would 
have  to  give  it  away.  In  that  very  fall  the  first  case  of  pellagra 
came  under  my  observation,  and  from  that  time  on  the  disease  has 
been  spreading.  The  first  year  I  had  three  cases  of  it.  I  did  not 
know  what  it  was;  but  I  treated  these  patients  symptomatically. 
The  disease  was  not  severe  in  its  type.  The  next  year  I  had  six  or 
seven  cases,  and  this  year  it  is  spreading  over  my  land  like  another 
Niagara.  Our  State  Officer,  Dr.  Sanders,  said  a  month  ago  it  was 
on  the  wane.  In  my  section,  in  the  last  six  weeks,  I  have  had  six 
new  cases  of  pellagra  to  develop,  mostly  amongst  children.  I  am 
treating  today  a  child,  two  years  of  age,  with  pellagra.  It  is  getting 
along  nicely.  The  idea  has  been  advanced  here  that  corn  is  doing 
the  damage.  Corn  is  one  of  the  chief  merchantable  commodities  of 
the  United  States,  but  I  tell  you,  gentlemen,  it  is  not  corn  according 
to  my  idea.  It  may  be  damaged  corn,  but  pure,  fully  developed, 
hardened  corn — hardened  by  the  rays  of  the  noonday  sun — will 
never  produce  pellagra.  That  is  my  idea  about  it,  and  we  should  be 
very  careful,  in  giving  our  ideas  here,  not  to  let  it  go  out  to  the  out- 
side world  that  corn  is  doing  this  mischief,  is  producing  this  disease. 
People  are  crazy  all  over  the  country  over  the  idea  that  corn  pro- 
duces pellagra. 

Dr.  Louis  Leroy,  Memphis,  Tennessee:  The  subject  of  the 
etiology  of  pellagra  is  the  all  important  one  of  this  conference.  It 
strikes  me  that  if  we  look  back  on  the  etiology  of  any  of  these  dis- 
eases it  is  only  a  year  or  two  ago,  comparatively  speaking,  when 
reports  as  to  climatic  conditions,  rain-falls,  etc.,  were  tabulated  and 
brought  forward  to  explain  the  etiology  of  typhoid  fever.  We  have 
had  all  kinds  of  statistics  to  show  that  typhoid  fever  was  caused  by 
certain  conditions  of  clim.ate  and  certain  conditions  of  rain-fall.     I 


197 

believe  that  we  are  not  far  from  a  similar  condition  here,  when  we 
seek  to  ascribe  to  moldy  corn  and  improper  harvesting  of  it  the 
etiological  factors  in  the  development  of  pellagra.  That  there  is  a 
relationship  existing  between  pellagra  and  corn,  I  do  not  believe  we 
can  doubt,  any  more  than  we  can  doubt  the  existence  of  a  relation- 
ship between  impure  water  or  impure  milk  and  typhoid  fever;  but 
that  does  not  mean  that  the  last  word  has  been  said  by  any  means 
as  to  the  etiology  of  pellagra.  What  is  it  that  makes  corn  moldy? 
It  is  not  the  climate  that  made  it  go  bad.  The  corn  crop  has  been 
blighted,  but  that  is  not  what  made  it  go  bad.  It  is  some  other 
living  form  of  organism  which  is  gaining  a  livelihood  on  that  corn 
upon  which  it  can  grow  after  it  is  once  blighted,  or  from  climatic 
conditions,  until  the  protective  coat  of  the  corn  has  not  had  an 
opportunity  to  form  fully,  or  for  some  reason  through  the  improper 
formation  of  the  husk  it  has  gained  entrance  to  the  kernel,  and 
while  we  perfectly  admit  that  corn  plays  an  etiological  role,  we  can- 
not stand  up  and  say  that  corn  is  the  cause,  and  the  only  cause,  of 
pellagra.  There  is  something  else,  and  we  want  to  find  out  what 
that  something  else  is  in  the  corn.  Corn  is  only  a  half  step  forward. 
We  cannot  be  satisfied  by  letting  the  case  rest  at  that  point.  Whether 
this  disease  be  protozoal  or  bacterial  in  origin  we  do  not  know.  Our 
attitude  must  be  this,  that  up  to  the  present  point  corn  has  acted 
as  a  carrier  of  the  infection ;  that  in  certain  cases  corn  may  carry  the 
disease,  and  in  saying  that  it  will  not  bring  us  into  conflict  with  com- 
mercial interests.  While  we  admit  the  likelihood  of  damaged  corn 
as  a  cause  of  the  disease,  at  the  same  time  it  does  not  leave  out  of 
consideration  the  fact  that  a  protozoal  infection,  or  infection  by  some 
micro-organism,  is  the  cause  of  the  disease.  Personally,  our  cases 
that  have  been  reported  show  unquestionable  evidence  of  transmis- 
sibility  of  the  disease,  and  for  that  reason,  in  addition  to  others,  it 
is  my  personal  opinion  that  some  day  we  shall  discover  a  living 
cause;  but  let  us  not  go  upon  record  as  saying  it  is  corn,  and  only 
corn,  but  let  us  say  it  is  corn  and  something  in  the  corn  that  may 
cause  the  disease.     (Applause.) 

Dr.  J.  H.  Taylor,  Columbia,  South  Carolina:  With  reference  to 
the  use  of  mercury  in  the  treatment  of  pellagra,  I  will  say  that  Dr. 
Wright,  of  Colorado,  noted  the  happy  effect  of  mercurial  treatment 
in  tuberculosis  cases  and  has  been  using  the  succinamide  of  mercury 
in  their  treatment.  He  has  published  several  articles  on  this  subject, 
reporting  splendid  results. 


198 

With  Wright's  success  in  mind,  Dr.  Lavinder,  while  stationed  here 
at  Columbia,  in  ten  cases  of  pellagra  used  the  succinamide  of  mer- 
cury in  one-eighth  grain  doses  given  hypodermically.  One  case 
showed  decided  improvement.  This,  however,  was  a  patient  badly 
infected  with  syphilis.    The  other  cases  showed  no  improvement. 

With  reference  to  the  remarks  of  Dr.  Nichols,  who  said  v/e  must 
go  cautiously  and  gingerly,  so  far  as  corn  is  concerned,  I  agree  with 
him  that  we  must  continue  our  investigations  and  efforts  in  the  com 
direction.  There  is  no  question  as  to  some  relationship  between  corn 
and  the  production  of  pellagra ;  therefore,  we  must  cut  out  the  bad 
corn,  although  we  do  not  know  as  yet  what  is  behind  it.  Corn  is  a 
medium  in  some  way,  and  we  shall  find  out  some  day  how. 

We  do  not  know  the  cause  of  beri-beri,  but  it  is  said  to  be  asso- 
ciated with  the  eating  of  rice,  and  in  the  same  way  the  eating  of  com 
may  be  associated  with  pellagra.  I  have  seen  but  one  case  of  beri- 
beri, and  that  was  shown  me  by  Dr.  Sandwith  in  London  this  sum- 
mer at  the  London  School  of  Trophical  Medicine.  I  know  very  little 
about  the  subject. 

As  to  the  remarks  of  Dr.  Watson,  I  expected  more  from  him  and 
was  a  little  disappointed.  I  am  glad  to  see,  however,  that  he  only 
criticises  the  arsenic  treatment  in  cases  of  pellagra.  The  rest  of  my 
paper  he  seems  to  pass  over  without  objection.  I  referred  to  Dr. 
Babcock  my  statement  about  improvement  in  the  early  stages  of 
pellagra  from  the  use  of  Fowler  solution  and  he  sanctioned  it.  I 
have  never  said  that  arsenic  cured  pellagra,  but  it  is  the  only  drug 
with  which  we  can  note  any  improvement  traceable  to  its  use. 

Dr.  Whaley,  I  think,  is  talking  about  blind  staggers  from  the 
toxins  of  bad  corn,  in  all  of  which  I  agree  with  him  perfectly.  He 
has  not  been  discussing  pellagra. 


199 


PERSONAL  EXPERIENCE  WITH  DAMAGED  CORN 

J.   SWINTON   WHALEY 

EDISTO    ISLAND^    S.    C. 

Gentlemen,  when  I  survey  this  august  assemblage  and  view  the 
many  M.  D.s  and  men  of  scientific  thought  and  investigation  coming 
from  every  part  of  our  country,  the  question  comes  to  me,  What 
has  a  plain  planter  and  common  farmer  to  do  in  their  midst? 

In  an  unguarded  moment  I  mentioned  to  Dr.  Babcock  an 
experience  I  had  had  with  damaged  corn,  and  he,  always  looking 
for  facts  and  seeking  to  know  the  truth  underlying  all  conditions 
and  diseases,  thought  this  experience  of  mine  might  be  of  value  to 
the  conference,  so  at  his  request  I  am  here  to  tell  you  about  it,  and 
what  I  know  of  damaged  corn. 

Damaged  corn!  Why  should  it  be  considered  here?  Because 
some  have  thought  this  to  be  the  first  cause  of  the  dread  disease 
you  gentlemen  are  conferring  about. 

If,  as  has  been  asserted,  pellagra  in  man  and  what  we  farmers 
know  as  blind  staggers  in  horses  are  analogous  diseases  and  pro- 
duced by  the  same  cause,  then,  this  being  true,  it  is  well  for  you  to 
consider  the  matter,  look  into  this  subject,  and  find  out  how  the  corn 
becomes  damaged. 

I  had  heard  of  my  neighbors  losing  their  animals  with  blind 
staggers,  and  that  it  comes  from  feeding  bad  corn,  but  I  did  not 
realize  it  until  in  the  fall  of  1903  I  lost  two  mules  and  one  horse,  and 
as  I  could  not  determine  the  cause  and  not  knowing  how  far  the 
disease  might  go,  I  sent  for  a  veterinary  surgeon  to  examine  my 
stock.  To  my  surprise  he  found  several  more  mules  and  horses 
affected.  He  immediately  told  me  I  was  feeding  on  damaged  corn. 
I  did  not  agree  with  him,  as  to  all  appearance  the  corn  I  was  feed- 
ing was  as  good  as  I  usually  made.  He  insisted  that  we  make  an 
examination.  To  do  this  we  had  to  shell  some  of  the  corn,  as  I  was 
feeding  on  ear  corn.  Upon  doing  so  we  found  the  grain  to  be  black 
about  the  eye.  He  advised  me  to  stop  feeding  on  it  at  once  or  I 
would  lose  all  of  my  stock.  I  told  him  I  had  nothing  else  to  feed  on 
and  I  could  not  get  oats,  which  he  advised  me  to  order,  for  several 
days.  "Better  to  feed  on  hay  if  you  want  to  save  this  stock."  I  did 
so  and  lost  no  more  with  blind  staggers,  and  from  then  on  I  have 
used  oats  and  only  corn  that  I  know  has  been  properly  cured. 

Now,  how  was  it  that  this  corn  of  mine  became  damaged? 
Because,  realizing  the  truth  of  the  statement  that  there  is  as  much 


200 

feeding  value  in  the  stalks  or  stover  as  in  the  grain,  I  attempted  to 
cure  my  crop  after  the  shocking  method  instead  of  the  old-time 
method. 

Now,  as  most  of  this  assemblage  are  probably  not  familiar  w^ith 
the  old-time  method  of  harvesting  the  corn  crop  in  the  South,  I 
think  I  am  justified  in  taking  up  your  time  for  a  few  moments  in 
describing  it,  for  I  am  sure  I  can  convince  you,  as  I  have  been  to  my 
cost,  that  the  trouble  is  not  in  the  corn  itself,  but  in  the  way  it  has 
been  harvested. 

The  custom  in  the  South  used  to  be  to  strip  the  blades  as  soon  as 
the  shucks  started  to  turn  yellow  and  turn  the  stalk  down  below  the 
ear,  then  the  corn  was  not  broken  in  until  last  of  October  or  first 
of  November.  This  permitted  it  to  cure  thoroughly  and  the  turning 
down  of  the  stalk  prevented  any  rain  getting  in  the  ear,  especially 
where  the  shuck  may  have  been  broken  by  birds  or  from  other 
causes,  and  so  long  as  I  continued  to  use  this  method  I  did  not 
know  what  blind  staggers  Avas.  But  in  my  desire,  as  stated  above,  to 
utilize  the  whole  plant,  I  cut  the  stalks  down  at  the  time  I  usually 
stripped  the  blades  and  shocked  them  up,  leaving  those  shocks  in  the 
field  exposed  to  all  kinds  of  weather  with  most  of  the  ears  turned  up 
for  a  month  or  so,  then  shucked  the  corn  and  stacked  stalks  to  be  fed 
as  roughage  during  the  winter.  The  roughage  was  fine  for  the  cattle, 
and  I  congratulated  myself  that  I  had  hit  upon  a  way  to  carry  my 
cattle  through  the  winter  in  fine  condition,  but  this  gain  was  nothing 
to  the  loss,  as  I  found  to  my  cost,  in  damaged  corn.  So  I  abandoned 
that  method  and  have  had  no  more  blind  staggers. 

Many  of  my  neighbors  on  the  truck  farms  have  been  obliged 
to  give  up  the  shocking  method,  as  some  of  them  have  lost  in  one 
season  their  entire  stock  of  work  animals,  and  while  some  have  to 
continue  to  practice  that  method  on  account  of  having  to  have  the 
land  on  which  a  crop  of  corn  has  been  raised  after  one  of  early 
truck,  such  as  cabbage  or  potatoes,  to  prepare  for  the  same  the  next 
spring,  they  have  to  be  very  careful  in  feeding,  one  trucker  telling 
me  that  he  not  only  sorted  out  all  the  rotten  ears  when  breaking, 
but  had  all  dotted  ends  cut  off  before  feeding  to  stock. 

For  the  past  few  years  I  have  had  to  stop  buying  Western  corn, 
and  have  bought  oats  entirely,  as  the  corn  has  not  been  fit  to  feed 
on,  being  in  the  same  condition  my  damaged  corn  was.  Why  is  it 
that  you  cannot  get  the  good  corn  from  the  West  now  that  one  could 
in  the  past?  I  believe  for  the  same  reason  I  damaged  mine.  The 
corn  is  cut  and  shocked,  exposed  to  rain  and  possibly  snow,  both 


20I 

soaking  into  the  ear,  then  it  is  taken  to  the  shredder,  the  stalk  fed 
to  the  machine  and  the  corn  comes  out  at  one  end  and  the  stover  at 
the  other,  but  what  does  the  man  who  is  feeding  the  machine  know 
of  the  condition  of  the  corn  he  is  shelHng?  The  fans  may  take  out 
those  grains  that  are  so  rotten  as  to  become  light,  but  what  of  the 
heavy  grains  with  the  black  eye,  the  blind  staggers  and  pellagra  pro- 
ducing grains — they  go  to  market.  And  if  we  have  damaged  corn 
we  have  damaged  grist  and  meal.  It  seems  almost  out  of  place  in 
a  gathering  like  this  to  have  a  planter  talk  of  the  different  ways  of 
curing  corn.  But  if  blind  staggers  in  horses  and  pellagra  in  man 
are  one  and  the  same  disease,  and  to  my  lay  mind  the  first  time  I  saw 
a  case  of  pellagra  the  movements  of  the  patient  resembled  that  of  a 
horse  in  the  last  stages  of  blind  staggers,  then  this  matter  of  dam- 
aged corn  becomes  of  first  importance,  for  that  it  is  a  sure  cause  of 
blind  staggers  is  an  accepted  fact.  Especially  when  the  corn  is 
raised  after  truck.  One  and  all  realize  this  and  are  seeing  to  it  that 
their  corn  is  properly  cured.  We  have  no  blind  staggers  in  horses 
or  mules  without  damaged  food.  No  impure  water  produces  it,  for 
in  every  case  stop  the  bad  corn  and  you  stop  the  disease  no  matter 
what  the  oher  conditions  are. 

I  realize,  gentlemen,  that  this  is  a  large  and  important  subject, 
for  we  are  attributing  to  one  of  our  greatest  and  most  valuable 
products  the  cause  of  a  most  malignant  and  far-reaching  disease.  Is 
this  to  jeopardize  the  usefulness  of  the  product?  Not  at  all,  for  it 
is  only  when  it  is  bad  that  the  results  are  evil,  so  we  must  see  that 
no  damaged  corn  or  its  resultant  products  are  put  on  the  market. 
For  the  people  amongst  us  that  are  showing  the  largest  percentage 
of  pellagra  are  those  of  our  population  whose  chief  food  is  corn  and 
its  resultant  products  manufactured  and  shipped  to  us  from  the 
corn-growing  States  of  the  West,  for  the  advent  of  pearl  grist  and 
meal  has  taken  the  place  of  the  home-made  product  and  we  are  not 
getting  the  good  article  now  lihat  we  did  when  it  was  first  introduced, 
and  we  must  publish  its  ill  effects  universally  and  we  will  have  it 
remedied,  for  just  as  soon  as  the  grower  and  the  handler — the  man 
through  whose  hands  it  passes — are  made  to  realize  that  damaged 
corn  and  its  resultant  products  are  unsalable  they  will  mend  their 
methods. 

Let  the  Government  bring  its  pure  food  law  to  bear  and  see  that 
the  manufacturer  does  not  put  a  bad  product  on  the  market  and  I 
think  you  will  see  a  great  change  in  the  number  of  negroes,  espe- 
cially, having  the  disease. 

Hoping  my  effort  may  have  added  some  little  to  the  solving  of  the 
problems,  I  must  thank  you  for  your  patient  hearing. 


202 


SOME  FACTS  AND  THEORIES  OF  PELLAGRA 

H.   E   m'CONNELL,    M.   D. 

CHESTEKj    S.    C. 

While  material  is  being  collected  as  to  the  nature  of  pellagra,  it  is 
the  duty  of  every  practicing  physician  to  contribute  his  mite,  and 
consequently  I  will  say  that  the  facts  herein  set  forth  are  drawn 
from  my  personal  experience  with  twenty-four  cases  in  my  home 
county  of  Chester,  dating  back  to  1903. 

-.After  the  Conference  of  last  year,  which  was  so  largely  attended 
and  in  which  so  much  interest  was  shown,  I  had  hoped  before  an- 
other twelve  months  had  rolled  around,  we  would  not  still  be  grop- 
ing in  the  dark,  but  that  we  could  lay  our  finger  on  the  etiological 
factor  and  say  this  fungus,  or  this  bacillus,  this  protozoa  causes 
pellagra.  And  even  that  the  name  itself  be  found  a  misnomer. 
Then,  too,  a  specific  cure  had  been  hoped  for,  either  medicinal  or  a 
serum,  but  still  we  must  wait  and  listen  to  the  theory  of  the  Zeist 
and  Anti-Zeist. 

In  each  of  my  cases  there  has  been  a  definite  history  of  corn  pro- 
ducts of  questionable  character  being  used,  and  this  puts  me  in  the 
class  with  those  still  holding  to  the  maize  theory.  Then,  too,  I  can- 
not pass  lightly  over  the  history,  experience  and  teaching  of  the  past 
175  years.  As  we  were  wont  long  to  associate  malaria  with  damp 
lowland  and  stagnant  water,  the  sleeping  sickness,  to  living  near 
rivers  and  lakes  with  wooded  shores,  so  must  we  associate  pellagra 
with  spoiled  corn.  But  why  pellagra  in  America  at  this  late  date 
when  corn  had  been  the  staple  food  even  before  civilization  came 
to  our  shores  ?  Indeed,  it  seems  strange  that  after  the  lapse  of  cen- 
turies a  disease  due  to  corn  should  come  back  to  us  from  the  old 
world  when  the  seed  was  first  obtained  in  America.  I  believe  this 
fact  due  entirely  to  the  changed  methods  of  cultivating  and  harvest- 
ing corn,  whereby  un-matured  corn  is  placed  in  the  most  favorable 
condition  for  fermentation  and  fungus  growth. 

At  present,  as  a  xule,  it  is  always  handled  in  large  quantities  and 
by  machinery,  with  no  means  by  which  the  damaged  or  rotten  corn  is 
separated  from  that  which  is  sound  and  suitable  for  food.  It  is 
meal  from  such  corn  as  this  that  most  of  us  use  if  we  eat  corn  pro- 
ducts at  all.  In  my  town,  with  a  population  of  eight  to  ten  thousand, 
if  you  had  good  sound  corn  that  you  wished  ground  into  meal,  you 


203 

would  have  to  send  it  five  miles  to  the  nearest  mill,  and  then  with  the 
possibility  that  your  meal  be  infected  with  the  fungus  of  spoiled  corn 
being  ground  just  before  yours.  Often  the  doctors  are  asked:  Why 
don't  all  of  us  have  pellagra  because  nearly  all  Carolinians  eat  corn 
in  some  form?  My  reply  to  such  inquiry  is  by  explaining  the  dif- 
ferent degrees  of  resisting  power  peculiar  to  each  individual.  They 
had  as  well  ask  why  we  don't  all  have  tuberculosis  or  typhoid 
fever.  Often  the  laymen  ask  me  if  it  is  contagious.  My  reply  is  in 
the  negative,  for  if  it  were  with  the  association  I  have  had  with  my 
cases  I  would  have  contracted  it.  But  it  is  always  well  to  say  that 
the  only  way  to  avoid  it  is  to  avoid  spoiled  corn.  The  fact,  too,  that 
so  seldom  more  than  one  case  occurs  in  a  family  is  against  the  idea 
of  contagion.  In  my  experience,  in  only  two  instances  have  more 
than  one  case  been  observed  in  the  same  family. 

I  have  here  a  photograph  of  a  healthy  baby  three  years  old  who 
nursed  a  pellagrous  mother.     (Exhibit  photo). 

From  the  similarity  of  the  disease  in  all  cases  I  am  led  to  believe 
that  it  is  due  to  a  fungus  or  a  bacillus  with  their  toxines  associated 
with  spoiled  corn.  It's  port  of  entry  is  through  the  stomach  and 
intestines  and  when  once  engrafted  it  is  hard  to  dislodge.  All 
these  cases  had  in  the  beginning  a  stomatitis,  salivation,  burning  in 
the  stomach  and  diarrhoea,  more  marked  in  some  than  in  others. 
The  slower  developing  cases  usually  present  these  symptoms  twelve 
months  before  the  rash  appears,  the  acute  cases  after  a  few  weeks. 

By  this  rash  we  make  the  diagnosis  of  pellagra,  the  blood  show- 
ing no  specific  organism ;  varying  from  the  normal  only  by  a  slight 
lymphocytosis  and  the  urine  and  stools  containing  no  amoebae  nor 
bacillus  as  yet  of  recognized  pathogenicity.  I  further  believe  that 
this  fungus  is  unaffected  by  heat,  or,  which  is  more  probable,  enters 
the  stomach  with  poorly  cooked  food.  Apparently  cured  cases  seem 
to  relapse  easily  after  corn  products  are  used  even  though  they  be  of 
the  best  quality. 

While  the  stomach  and  intestines  are  the  primal  foci,  I  think  most 
of  the  symptoms  are  produced  by  the  action  of  the  toxines  on  the 
nervous  system  as  the  history  of  the  following  case  will  show  : 

Mrs.  C.  F.  S.,  age  fifty-eight.  Good  family  history,  eight  children, 
all  healthy.  Lived  on  farm  with  good  hygienic  surroundings.  Was 
called  to  see  her  on  December  31st;  with  slight  cerebral  hemorrhage 
affecting  the  right  hand  and  with  slight  aphasia.  No  heart  or  kid- 
ney lesion.  Arteries  somewhat  sclerosed.  Advised  light  diet  with 
plenty  of  milk  and  mush.     May  24th  she  had  a  second  attack  of 


204 

cerebral  hemorrhage,  was  completely  unconscious  for  several  days; 
right  hand  and  foot  paralyzed.  Consciousness  slowly  returned,  and 
gradually  some  use  of  the  foot,  but  not  much  of  the  hand  returned. 
Was  in  bed  three  or  four  weeks,  then  up  in  a  roller  chair.  .  Septem- 
ber 14th  was  again  called  to  see  her  and  found  her  with  a  sore 
mouth,  salivation,  burning  in  the  stomach,  diarrhoea  and  a  slight 
rash  on  left  hand  which  in  a  week's  time  was  typical,  but  no  rash  on 
the  paralysed  hand. 

This  to  me  was  a  point  of  interest  and  I  reasoned,  whether  cor- 
rectly or  not,  that  the  motor  area  in  the  brain  being  damaged  and 
the  trophic  nerves  along  with  the  motor  being  degenerated,  could 
not  transmit  the  stimulation  from  the  toxines  to  the  skin  and  produce 
the  erythema.  This  patient  did  not  improve  under  treatment  and 
died  suddenly  October  2nd,  1909,  from  cerebral  hemorrhage. 

Of  the  ten  cases  observed  in  death  the  minds  of  all  were  affected 
except  the  case  which  died  suddenly  already  referred  to.  In  all,  the 
last  few  days  of  life  were  distressing.  Of  the  ten  cases  seen  up  until 
the  1st  of  January,  1909,  seven  were  women  and  three  men,  and 
singularly  all  the  women  are  dead  and  all  the  men  living  and  appar- 
ently well.     One  of  whom  I  present  today. 

Mr.  W.  W.  Mc,  age  sixty-nine.  During  the  summe.  of  1906 
was  treated  by  Dr.  J.  M.  Brice,  was  so  reduced  by  the  disease  and 
mind  so  badly  affected  that  if  he  got  a  short  distance  from  his 
house  he  was  unable  to  find  his  way  back.  Was  seen  and  treated  by 
me  for  pellagra  during  the  spring  and  summer  of  1907.  Had  all 
the  typical  symptoms,  profuse  erythema  over  both  hands,  the  scars 
of  the  ulceration  you  can  yet  see.  Treatment :  Fluid  extract  Hydras- 
tis fifteen  drops  before  meals  and  ten  drops  of  nitro-muriatic  acid 
after  meals.  Plenty  of  milk,  eggs,  orange  juice  and  vegetable 
broths.  Strong  leucodescent  lamp  applied  to  his  hands  and  over 
the  region  of  his  stomach  until  the  skin  was  reddened.  This  light 
treatment  was  applied  by  Dr.  J.  G.  Johnston.  He  has  been  out  of 
doors  during  the  summer  of  1908-1909,  during  which  time  he  has 
taken  no  treatment,  yet  has  not  had  the  return  of  the  slighest  symp- 
tom.    Has  never  eaten  any  more  corn  bread. 

Of  the  fourteen  cases  seen  this  year  the  proportion  of  males  has 
increased  to  the  same  as  that  of  females,  seven  of  each.  Of  these 
two  females  (white)  and  one  male  (colored)  have  died.  Of  the  24 
cases  four  only  were  negroes.  Three  of  these  I  prescribed  for  dur- 
ing the  summer  of   1908,  as  suspected  cases  of  pellagra,  only  to 


205 

have  my  suspicions  verified  the  following  spring.     The  rash  is  not 
so  distinct  or  as  easily  recognized  as  in  the  whites. 

From  these  cases  it  seems  that  no  age  or  sex  or  rape  is  exempt. 
In  my  earlier  experience  women  seemed  to  be  more  affected  than 
men,  and  not  until  this  year  did  I  see  a  negro  with  the  disease.  It 
may  be  that  the  negroes  have  a  greater  immunity,  as  we  all  know 
they  eat  more  corn  bread  than  the  whites. 

The  course  of  the  disease  has  varied  from  three  years  to  a  few 
weeks.    The  most  acute  case  being  Mrs.  B.,  with  this  history : 

Mrs.  B.,  age,  20.  Nursing  baby  16  months.  Good  family  his- 
tory. Developed  diarrhoea  and  sore  mouth  in  August,  and  was  sick 
about  three  weeks  when  a  rash  appeared  on  her  hands.  Rash  was 
severe  and  extended  high  up  arm.  After  paying  her  a  few  calls, 
thinking  it  a  simple  diarrhoea,  was  surprised  to  find  it  a  pellagrous 
rash  when  I  was  called  in  again.  Her  baby  was  weaned  and  is  now 
in  perfect  health.  This  is  the  most  acute  case  I  have  seen  as  the 
prodromal  symptoms  were  not  longer  than  three  weeks.  Treat- 
ment :  Fowler's  solution  and  Hydrogen  Peroxide.  In  two  weeks 
the  sore  mouth  and  rash  was  gone  and-  she  seemed  well  as  you  will 
see  by  photo.  (Exhibit  photo).  She  does  not  eat  any  more  corn 
bread. 

In  regard  to  treatment  will  say  that  atoxyl  was  given  widely  this 
year,  but  not  hypodermically,  as  these  patients  were  not  directly 
under  an  attendant  capable  of  giving  these  injections.  The  results 
have  not  been  superior  in  my  hand  to  Fowler's  Solution  and  Hydro- 
gen Peroxide.  The  leucodescent  light  had  the  most  beneficial  effect 
on  the  erythema  of  any  remedy  tried.  The  two  little  boys,  whose  his- 
tories are  here  attached,  were  treated  with  Fowler's  Solution,  the 
older  one  receiving  Atoxyl  in  the  beginning  and  later  changing  to 
Fowler's  Solution  and  Hydrogen  Peroxide,  with  equal  or  more 
benefit.  The  younger  was  treated  entirely  with  Fowler's  Solution 
and  Hydrogen  Peroxide. 

L.  P.,  age  nine.  Father  and  mother  both  healthy.  Bowel  trouble 
began  in  March,  1909,  also  sore  mouth.  History  of  some  bowel 
trouble  in  summer  of  1908.  Skin  eruption  first  seen  in  June.  Rash 
on  hands,  feet,  legs,  and  a  ring  around  his  neck  like  a  collar.  Treat- 
ment Atoxyl  and  Hydrogen  Peroxide,  later  Fowler's  Solution. 
Much  improved. 

J.  P.,  age  five.  Bowel  trouble  began  about  last  of  July.  Skin 
eruption  came  on  the  last  of  August;  very  distinct  on  hands,  feet 


206 

and  legs.  Both  boys  ate  toll  corn  last  year,  and  shipped  meal  this 
year.    Treatment:  Fowler's  Solution.    Very  much  improved. 

The  only  case  treated  with  Soamin  was  Mr.  McD.,  who  was 
treated  with  it  here  in  the  hospital,  and  it  is  being  continued  once 
a  week  in  my  office. 

W.  S.  McD.,  age  40.  Farmer.  Had  rash  on  hands  and  sore 
mouth,  but  not  much  diarrhoea  during  summer  of  1906- 1907.  Was 
diagnosed  as  pellagra  by  me  in  spring  of  1908.  Had  some  treat- 
ment, but  not  continuous.  During  spring  of  1909  the  sore  mouth 
and  rash  on  hand  was  much  worse.  Was  treated  with  Atoxyl  and 
Hydrogen  Peroxide  without  benefit.  His  mental  symptoms  becom- 
ing so  bad  that  on  April  10  he  was  committed  to  State  Hospital. 
Here  he  received  Soamin  and  now  you  see  him  today  apparently 
well.  During  the  spring  of  1906  he  ate  meal  from  toll  corn.  Does 
not  eat  any  more  corn  bread,  but  says  he  did  eat  some  roasting  ears 
while  here  in  the  hospital  and  it  did  him  no  harm. 

Realizing  that  conclusions  drawn  from  a  few  cases  are  apt  to  be 
fallacious,  these  opinions  here  expressed  are  in  no  way  meant  to  be 
final,  but  are  meant  to  be  changed  when  the  weight  of  evidence 
tips  the  balance  in  another  direction. 


DISCUSSION  ON  THE  PAPER  OF  DR.  McCONNELL. 

Dr.  W.  B.  Young,  Rock  Hill,  South  Carolina :  I  would  like  to 
ask  Dr.  McConnell  what  he  used  hydrogen  peroxide  for.  What  was 
his  purpose? 

Dr.  McConnell:  I  used  it  at  the  suggestion  of  another  phy- 
sician as  a  mouthwash  as  well  as  internally,  and  I  must  say  that  it 
relieves  the  sore  mouth  in  these  cases  better  than  anything  I  have 
tried. 


207 


SYMPTOMATOLOGY  OF  PELLAGRA  AND  REPORT  OF 

CASES 

J,  J.   WATSON,   M.  D. 

COLUMBIA^    S.    C. 

Definition:  Pellagra  is  an  endemic  disease  attributed  to  eating 
Indian  corn  infected  with  certain  hyphomycetes.  It  is  characterized 
by  digestive  disorders ;  symmetrical  dermatitis  on  parts  of  the  body 
exposed  to  the  sun  or  subjected  to  constant  pressure,  various  mental 
phenomena,  principally  depression,  and  in  most  cases  by  symptoms 
referable  to  spinal  degeneration. 

Symptoms :  The  malady  is  so  insidious  in  its  onset  that  it  is  diffi- 
cult to  state  absolutely  what  are  the  earliest  premonitory  symptoms. 
The  first  thing  usually  complained  of  by  the  patients  is  some  gastro- 
intestinal disorder ;  this  may  be  loss  of  appetite,  burning  sensation 
in  epigastrium,  excessive  desire  for  food  or  drink,  or  more  often 
diarrhoea  with  more  or  less  stomatitis  and  salivation. 

Soon  after  these  digestive  disorders  manifest  themselves  or  coinci- 
dent with  them  the  patient  detects  a  disinclination  to  any  exertion, 
becomes  irritable  and  sleepless.  Duties  that  were  formerly  dis- 
patched with  a  feeling  of  pleasure  are  now  looked  upon  with  a  dread ; 
and  procrastination  takes  the  place  of  habits  of  promptness ;  so  that 
the  personal  appearance  of  the  victim,  or  the  aspect  of  the  home  and 
children,  if  the  sufferer  is  a  woman,  indicates  neglect;  all  of  which 
is  evidence  of  the  psychic. depression  that  forms  later  a  prominent 
figure  in  the  clinical  picture  of  the  disease.  After  these  symptoms 
have  persisted  with  usually  increasing  severity,  in  some  cases  for 
weeks,  in  others  for  months,  the  characteristic  symptom  of  the 
disease  almost  invariably  appears,  namely :  Erythema  on  the  hands 
and  arms  not  covered  by  the  clothing. 

The  Skin  Eruption :  This  may  be  either  dry  or  wet. 

Dry  form :  The  eruption  appears  usually  in  the  early  spring 
months,  and  while  it  is  the  most  characteristic  objective  feature  of 
the  disease,  it  is  subjectively  one  of  the  least  important  as  very  few 
of  the  patients  suffer  any  physical  discomfort  from  it  other  than  a 
burning  sensation,  complaining  principally  of  the  unsightlessness. 
The  eruption  commences  as  an  erythema  suggesting  sunburn  on  the 
backs  of  the  hands,  and  extensor  surface  of  forearms,  extending 
up  the  arms  to  the  point  that  the  sleeves  reach,  and  ends  abruptly 
there,  being  absolutely  symmetrical  if  the  sleeves  are  symmetrical, 


208 

which  is  usually  the  case.  In  persons  who  do  not  "hold  their  hands" 
the  eruption  extends  to  the  flexor  surface  in  a  characteristic  shape, 
commencing  on  the  radial  border  it  extends  toward  the  ulner  by  an 
oblique  line  forming  a  patch  of  erythema  on  the  flexor  surface 
somewhat  triangular  in  shape,  the  base  of  the  triangle  being  the 
radius  and  the  apex  near  the  styloid  process  of  ulner.  Patients 
who  are  well  advanced  in  the  disease  and  unable  to  work,  and  who 
"sit  about"  and  "hold  their  hands"  have  the  eruption  on  the  flexor 
surface,  to  the  same  extent  as  on  the  extensor.  The  erythema 
lasts  for  a  few  days  and  then  commences  to  fade,  and  the 
skin  to  desquamate  in  fine  scales,  if  the  dermatitis  has  been  mild. 
As  the  redness  fades  the  site  of  the  erythema  assumes  a  somewhat 
cyanotic  hue,  this  is  gradually  replaced  by  a  characteristic  light  liver 
or  chocolate  color,  which,  if  once  seen,  cannot  be  mistaken  or  con- 
founded with  any  other  skin  disease.  In  negroes  it  is  readily  recog- 
nized by  an  increase  of  pigmentation,  the  site  of  the  eruption  appear- 
ing as  though  soot  had  been  smeared  on  that  part  of  the  hand  and 
arm. 

The  patients  often  make  vain  attempts  to  remove  the  dirty  appear- 
ance of  the  hands  with  soap  and  v/ater.  After  a  time  this  eruption 
scales  off  and  leaves  the  hands  soft,  velvety  and  glistening,  quite 
a  contrast  to  the  dirty  hands  that  they  were  the  sorrowful  posses- 
sors of  only  a  few  weeks  before,  but  like  Banquo's  ghost,  it  has 
come  to  stay  for  a  term;  the  erythema  re-appears  and  the  eruption 
follows  the  same  course  as  previously  described ;  this  may  happen 
several  times  during  the  summer.  As  a  result  of  these  repeated 
inflammations  the  skin  of  the  hands  become  thickened,  hard,  wrin- 
kled and  inelastic,  and  frequently  deep  fissures  form  on  the  fingers, 
notably  the  index  finger,  at  or  near  the  first  joint.  Portions  of  the 
body  covered  by  the  clothing  subjected  to  pressure  also  shows  the 
eruption  in  some  cases.  The  skin  over  the  olecranon,  trochanter, 
sacrum  and  knees  being  especially  liable  to  become  affected.  The 
forehead,  face  and  neck  are  often  the  seats  of  the  eruption.  In 
those  who  go  barefooted  the  feet  and  legs  do  not  escape.  The 
eruption  commences  in  the  spring  months  and  persists  until  July, 
August  or  September,  and  then  disappears  to  make  its  appearance  in 
the  following  spring.  In  some  cases  there  is  a  mild  relapse  in 
October.  The  crowning  characteristics  of  the  pellagra  eruption  are 
its  symmetry  and  color. 

After  the  discolored  skin  ha?  been  exfoliated  there  usually  remains 
a  fringe  of  dirty  appearing  epithelium,  a  relic  of  the  line  of  demar- 


ILLUSTRATION  NO.   II. 

Pellagrous  eruption  on  face,  neck,  elbows,  hands  and  knees.  This  case 
did  not  have  the  usual  winter  intermission  of  pellagrous  syndromes  for 
last  three  years  of  life.     Died  10  days  after  this  photograph  "was  taken. 


209 

cation  of  the  dermatitis.  In  some  cases  the  sebaceous  glands  on 
and  around  the  nose  are  hyperactive,  there  being  a  seborrhea.  Pur- 
puric spots  are  sometimes  seen  on  the  hands  and  face,  a  favorite 
site  being  under  the  eyes,  here  the  spots  have  a  crescentic  shape 
and  are  symmetrical.  On  the  hands  these  spots  are  sometimes  on 
the  palmer  surface. 

Wet  form :  This  differs  only  in  degree.  Where  the  dermatitis  is 
severe  bullae  form,  sometimes  containing  serous,  serosanguineous 
or  seropurulent  fluid,  when  the  bullse  break  large  ulcers  are  left  to 
mark  their  site,  or  large  flakes  of  skin  desquamates,  leaving  a  raw 
surface,  slight  cicatrices  remain  as  an  evidence  of  former  ulceration. 
"The  whole  clinical  puncture  being  analogous  to  a  burn  of  the  first 
degree."  (Dr.  Babcock).  The  wet  form  involves  a  greater  area 
than  the  dry,  such  as  the  axillae,  groins,  etc.  This  form  has  been 
frequently  diagnosed  as  dermatitis  exfoliativa.  The  eruption  is  an 
index  of  the  severity  of  the  disease;  an  extensive,  severe  eruption 
usually  bespeaks  a  severe  infection. 

Digestive  disorders:  The  buccal  mucosa  becomes  very  red,  the 
tongue  and  mucosa  of  lips  showing  particularly  this  characteristic 
symptom.  If  the  throat  is  examined  this  redness  will  be  observed 
as  far  as  one  can  see  into  the  pharynx.  Flakes  of  exfoliated 
epithelium  will  be  seen  adhering  to  the  gums,  and  the  tongue  being 
denuded  of  its  epithelium  is  smooth  and  glistening.  Now  its  color 
being  a  cardinal  red  and  it  being  a  cardinal  symptom  of  the  dis- 
ease, I  have  denominated  it  the  cardinal  tongue.  Sandwith  calls 
it  the  "bald  tongue."  This  stomatitis  is  accompanied  by  a  very  pro- 
fuse flow  of  thick  saliva,  in  some  cases  so  profuse  that  the  saliva 
dribbles  out  the  corners  of  the  patient's  mouth.  Ulcers  often  form 
on  the  tongue.  Intelligent  patients  suspect  they  have  been  salivated 
by  mercury.  When  the  mouth  is  opened  strings  of  saliva  will 
extend  from  the  upper  to  the  lower  teeth.  My  attention  was  directed 
by  Dr.  Babcock  over  a  year  ago  to  small  black  or  bluish  black  spots 
on  the  tongue,  and  since  then  I  have  observed  these  papilae  in  a 
number  of  cases,  all  negroes.  The  name  of  "stipple  tongue"  has 
been  given  this  condition  by  Dr.  Lavinder.  The  tongue  may  be 
either  pointed  and  tremulous,  or  large,  flabby,  swollen  and  indented. 

The  salivary  glands  may  be  swollen  and  tender,  this  with  the  sali- 
vation and  condition  of  the  swollen  gums  has  been  mistaken  for 
mercurial  salivation,  but  just  remember  that  in  mercurial  salivation 
there  is  always  quite  a  disagreeable  odor  to  the  breath,  and  while 
there  is  an  odor  to  the  salivation  in  pellagra,  it  is  not  the  same  dis- 
14.— p.  c. 


2IO 

gusting  foetid  odor  that  is  characteristic  of  the  mercurial  ptyaliza- 
tion. 

The  acme  of  the  stomatitis  corresponds  to  the  acme  of  the  erup- 
tion on  hands.    Other  mucous  membranes  are  inflamed,  proctoscopic 
examination  reveals  a  bright  red  mucous  as  far  up  the  gut  as  can    «■ 
be  seen. 

Hemorrhoids  are  sometimes  complained  of.  One  of  my  patients 
thus  complaining  showed  on  examination  only  an  intense  redness 
of  the  mucosa,  still  she  insisted  that  she  suffered  acutely  from  piles. 
'This  patient  was  then  in  a  state  of  mild  delirium,  and  probably  there 
was  some  irritation  that  caused  her  to  refer  to  trouble  in  that  local- 
ity. She  was  far  advanced  in  the  disease,  and  this  was  the  only 
symptom  complained  of.  It  is  not  unusual,  however,  for  patients  to 
complain  of  discomfort  in  this  locality.  The  mucosa  of  the  vagina 
is  also  a  seat  of  inflammation  and  vulvovaginitis  is  not  at  all  infre- 
quent. 

Stomach :  Burning  sensation  in  the  oesophagus  and  stomach  is 
quite  frequently  present.  Pyrosis  is  sometimes  a  prominent  feature 
with  or  without  belching.  "Pyrosis  is  never  absent."  (Lombroso.) 
Vomiting  occasionally  occurs,  but  is  not  a  constant  feature  of  the 
disease.  When  the  disease  is  advanced  dysphagia  is  complained  of 
by  some  patients,  and  this  may  be  accompanied  by  strangling  when 
fluids  are  taken. 

Marked  gastric  symptoms  are  in  evidence  in  some  cases.  I  have 
known  a  case  of  pellagra  diagnosed  as  gastric  cancer.  The  only 
abnormality  detected  by  abdominal  section  was  an  excessive  redness 
of  the  peritoneal  coat  of  stomach.  After  a  few  days  the  patient  was 
rolled  out  into  the  sun  and  soon  there  appeared  on  her  forehead  and 
hands  an  intense  erythema.  This  aroused  suspicion,  and  two  com- 
petent consultants  v/ere  called  in.  From  the  history  of  repeated  at- 
tacks of  eruption  and  the  picture  presented  by  patient,  the  diagnosis 
of  pellagra  was  made  and  the  subsequent  course  of  eruption  (color, 
etc.),  tongue,  diarrhoea  and  depression,  put  the  diagnosis  beyond 
doubt.     Hematemesis  is  sometimes  seen. 

Diarrhoea:  This  is  a  feature  of  the  disease  at  some  time  in  its 
course.  It  varies  from  a  few  soft  stools  a  day  to  twenty  or  more, 
sometimes  they  contain  blood  and  mucous;  they  are  frequently  invol- 
untary when  the  patients  are  bedridden.  In  a  number  of  cases  I 
have  noticed  that  the  stools  are  as  frequent  at  night  as  in  the  day. 
The  diarrhoea  is  obstinate  and  not  affected  by  the  ordinary  treatment 
or  diet.    I  have  seen  it  persist  in  spite  of  large  doses  of  bismuth  and 


211 

opium,  and  a  rigid  diet,  and  improve  when  drugs  were  discontinued 
and  diet  not  restricted.  It  is  not  dependent  upon  errors  in  diet,  but 
is  a  neurophathic  manifestation  due  to  disease  of  the  spinal  cord  and 
the  sympathetic  system. 

The  fact  that  the  normal  reflex  in  the  intestines  is  greatly  in- 
creased by  the  pathological  changes  in  these  structures  may  explain 
the  diarrhoea;  since  it  produces  hyper  peristalsis,  in  the  same  man- 
ner that  irritants  applied  to  the  skin  produce  an  exaggerated 
vasomotor  dilatation  with  the  erythema  as  a  result. 

In  rare  cases  there  may  be  constipation.  These  cases  are  very 
mild  and  show  very  slight  mental  depression  or  none  at  all.  In  the 
terminal  stage  when  temperature  sets  in  the  diarrhoea  sometimes 
stops.  Hemorrhages  from  the  bowels  may  occur.  Meteroism  is 
present  with  the  diarrhoea  and  sometimes  persists  after  the  bowels 
have  lost  their  frequent  action.  The  diarrhoea  follows  the  same 
course  as  the  erythema  and  stomatitis,  i.  e.,  it  has  exacerbations  and 
remissions  and  persist  through  the  spring  and  summer  months,  with 
a  slight  recrudescence  in  October,  then  disappears  during  winter  to 
re-appear  the  follov/ing  spring. 

Pupils:  Pupillary  abnormalities  are  quite  striking  in  some  locali- 
ties and  in  some  seasons,  varying  in  the  same  locality  from  year  to 
year.  In  the  year  1908  in  South  Carolina,  pupillary  dilatation  was 
the  rule,  the  mydiiasis  being  extreme  in  some  cases.  It  may  be 
either  bilateral  or  unilateral,  if  unilateral  the  right  pupil  is  most 
apt  to  be  dilated.  During  this  year,  1909,  I  have  seen  few  cases  with 
dilated  pupils,  contraction  of  pupils  is  sometimes  met  with.  The 
pupils  react  sluggishly  to  both  light  and  accommodation  and  "resist 
the  action  of  homatropin  considerably  longer  than  the  normal."  (Dr. 
Whaley).  Diplopia  and  photophobia  are  not  unusual.  These  pupil- 
lary phenomena  must  be  due  to  a  disturbance  in  the  cilio  spinal  cen- 
ter. This  center  is  situated  in  the  spinal  cord  between  the  first 
cervical  and  second  dorsal  nerves,  the  portion  of  the  cord  that  is 
nearly  always  affected  in  pellagra. 

Pain  in  the  hack :  This  was  a  striking  feature  in  some  of  the 
Italian  cases  that  I  saw,  the  pain  being  so  severe  that  the  sufferers 
walked  stooped  over,  this  attitude  furnishing  one  of  the  seven 
varieties  of  the  disease  described  in  the  Italian  proverb.  I  have  had 
only  a  few  patients  to  complain  of  pain  in  back  among  the  number 
studied  in  America.  Pains  in  various  portions  of  the  body  are  often 
complained  of.  Tenderness  at  some  point  along  the  spinal  column  is 
almost  constant.    It  is  usually  in  the  mid  dorsal  region  and  is  easily 


212 

elicited  by  pressure  with  the  fingers  along  the  spine.  The  tender- 
ness varies  on  the  two  sides,  in  some  cases  being  more  acute  on  the 
right.  The  tenderness  is  not  over  the  spinous  processes,  but  over 
the  point  where  the  nerves  emerge  from  the  canal. 

Temperature  and  Pulse :  The  mild  cases  are  practically  afebrile, 
i.  e.,  temperature  less  than  lOO.  The  morning  temperature  is  often 
sub-normal  96  to  97  1-2.  Temperatures  of  102  to  108,  or  over,  are 
not  unusual  in  cases  progressing  to  a  fatal  termination  from  so- 
called  typhoid  pellagra. 

The  pulse  is  accelerated  80  to  100  in  ordinary  cases,  but  increases 
with  the  toxaemia  or  temperature,  and  counts  of  160  are  not  unusual 
in  fatal  cases.  Very  rapid  respiration  is  occasionally  encountered 
without  any  appreciable  cause  for  it. 

There  is  nothing  characteristic  about  the  urine,  except  that 
alkaline  urine  is  a  bad  prognostic  sign.  (Lombroso). 

The  reflexes  are  usually  exaggerated,  though  they  may  be  normal, 
diminished  or  lost.  Like  other  signs,  they  vary  with  locality  and 
season.  The  patella  reflex  being  especially  more  lively,  the  slight- 
est touch  eliciting  a  lively  jerk,  the  knee  jerk  varies  on  the  two 
sides,  in  some  cases,  being  more  lively  on  the  right,  the  side  that 
has  the  most  exquisite  spinal  tenderness.  In  very  severe  cases,  or 
rather  those  in  which  there  are  tetanic  contractions,  ankle  clonus 
may  be  found.  In  those  cases  that  are  paretic  the  reflexes  are 
abolished. 

There  is  usually  analgesia  or  anesthesia  at  the  site  of  the  eruption. 

Vertigo  is  complained  of  by  nearly  all  of  the  sufferers,  and  should 
always  be  asked  about,  if  not  mentioned  by  them.  Its  presence 
should  always  excite  suspicion,  and  other  pehagrous  stigmata  sought 
for. 

Psychic  Phenomena :  Briefly.  Mental  depression  is  as  constant  as 
the  erythema  and  diarrhoea,  and  varies  from  a  mild  case  of  the 
blues  to  severe  melancholia.  The  patients  seem  to  have  "forgotten 
how  to  laugh."  The  poor  sufferers  imagine  they  have  not  a  friend 
on  earth,  that  even  their  own  children  and  parents  dislike  them, 
and  have  some  irreconcilable  grievance  against  them.  They  are 
easily  provoked  to  anger,  and  in  many  ways  indicate  lack  of  mental 
force.  Hallucinations  and  delusions  are  sure  to  occur  at  some  time 
in  the  disease,  and  no  two  patients  will  have  the  same  delusions. 
In  Italy  10  per  cent,  become  insane.  As  yet  we  cannot  form  any 
opinion  as  to  what  portions  of  our  patients  will  become  insane,  but 


ILLUSTKATIOX  NO.  III. 


Showing  characteristic  facial  expression. 


213 

if  statistics  are  properly  kept  it  will  be  a  very  easy  matter  to  ascer- 
tain what  proportion  is  demented. 

While  pellagrins  are  never  loquacious,  at  times  they  are  com- 
plaining of  real  or  imaginary  ills.  As  the  disease  advances  they 
talk  less,  often  not  answering  questions,  and  finally  pass  into  a  state 
of  absolute  mutism.  This  portion  of  the  pellagrous  syndrome  is 
very  important,  and  pellagrous  insanity  properly  calls  for  separate 
consideration. 

Gait:  The  gait  is  eithe"  simple  paralytic  or  paralytic  spastic.  The 
patients  walk  with  their  legs  far  apart,  and  as  paresis  sets  in  the 
stride  is  very  much  decreased,  and  the  patient  assumes  a  peculiar 
shuffling  gait. 

Case  I  :  Mrs.  T.,  white,  widow,  no  children,  age  62,  family  his- 
tory good.  Always  in  good  health  until  present  illness,  which  com- 
menced December  ist,  1907,  with  diarrhea  and  lack  of  energy.  The 
diarrhea  gradually  became  more  severe  and  the  motions  were  as 
frequent  at  night  as  they  were  during  the  day.  About  January  ist, 
1908,  mouth  was  quite  sore  and  salivation  extreme,  mental  depres- 
sion and  weakness  gradually  increased  until  she  was  forced  to  take 
her  bed  about  May  ist.  The  eruption  appeared  on  hands  about 
March  15th,  and  was  so  severe  that  her  physician  thought  she  had 
gangrene;  temperature  ran  for  three  weeks  from  100  to  loi.  May 
23rd  admitted  to  Columbia  Hospital,  weight  89  pounds.  Visceral 
examination  negative.  Utine  normal,  pulse  68,  temperature  96  1-2 
degrees.  There  existed  on  hands  and  fore-arms  patches  of  pella- 
grous eruption,  the  dirty  fringe  being  very  noticeable.  The  palms 
of  the  hands  were  exfoliating  and  had  been  the  seat  of  an  intense 
dermatitis,  bullae  having  formed  on  them  and  contained  sero  pus ; 
she  endeavored  to  keep  her  hands  concealed,  as  they  were  unsightly, 
and  did  not  care  for  any  one  tcf  touch  them,  fearing  that  she  might 
contaminate  them;  there  was  also  a  patch  of  dermatitis  on  each 
elbow  about  the  size  of  half-dollar.  Tongue  and  buccal  mucosa 
very  red,  saliva  profuse  and  tenacious.  Patella  reflexes  exaggerated, 
right  most  lively,  pupils  contracted,  tenderness  in  mid  dorsal  region, 
right  side  more  tender  than  left,  vertigo  on  standing.  She  remain- 
ed in  hospital  until  November  30th,  1908.  During  that  time  she  had 
frequent  remissions  and  exacerbations  of  diarrhea,  they  being  most 
severe  from  time  of  admission  until  about  the  first  of  August,  when 
she  gradually  commenced  to  improve  in  her  physical  condition. 
The  greatest  number  of  stools  was  in  July  (i6th),  when  fourteen 
were  recorded  in  twenty-four  hours.     The  stools  were  principally 


214 

involuntary  from  May  30th  to  August  3rd.  Bed  sore  appeared 
June  1 2th.  Nausea  and  vomiting  June  4th,  and  continued  until 
July  15th.  All  medicine,  including  bismuth  and  opium,  was  dis- 
continued July  13th,  and  the  15th  there  was  no  nausea  or  vomiting. 
Herpes  zoster  developed  September  i6th.  As  her  physical  condition 
improved  her  mental  condition  became  worse,  she  imagined  she 
was  covered  with  microbes  and  every  day  would  have  great  num- 
bers of  fibers  of  lint  and  wool  in  a  pus  basin  to  show  me  "the  things 
that  were  tormenting  her  to  death."  The  latter  part  of  November 
she  became  excited  and  it  was  thought  best  to  transfer  her  where 
she  could  be  restramed.  She  was  sent  to  a  private  institution  at  the 
North  and  remained  there  until  June  of  this  year.  There  has  been 
no  recurrence  of  the  diarrhoea  or  eruption ;  she  is  the  picture  of 
perfect  health  today,  weighs  130  pounds. 

She  admits  being  very  fond  of  corn  bread,  that  she  ate  it  every 
day ;  she  also  states  that  for  m.onths  before  she  was  taken  sick  that 
neither  her  corn  bread  nor  hominy  were  properly  cooked,  the  servant 
she  had  at  that  time  being  very  careless. 

Case  2:  Mrs.  S.,  age  31,  white,  married,  three  children  living, 
four  dead,  no  miscarriages,  native  of  North  Carolina,  husband 
country  merchant,  distributing  considerable  quantities  of  shipped 
goods,  including  corn,  by  car  loads.  Health  always  good  until  four 
years  ago,  when  she  presented  the  pellagrous  syndrome,  diarrhoea, 
eruption  on  hands,  stomatitis,  salivation  and  vertigo.  These  lasted 
all  spring  and  summer,  disappearing  during  winter;  they  have  re- 
turned each  spring  with  increased  severity.  The  first  year  the  symp- 
toms were  noticed  quite  a  number  of  young  chickens  in  the  yard 
lost  their  feathers,  were  very  red,  did  not  grow,  and  finally  became 
ataxic  and  died.  She  was  in  a  state  of  valetudinarianism  practically 
for  four  years ;  being  frequently  accused  by  her  husband  of  being 
hysterical,  as  she  often  cried,  was  apprehensive  that  something 
dreadful  would  happen  to  her.  In  February,  1909,  complained  of 
burning  in  stomach,  later  diarrhoea,  eruption  and  salivation  ap- 
peared, symptoms  being  more  severe  than  any  previous  attack. 

Condition  June  13th,  1909,  fairly  well  nourished  woman.  Facial 
expression  that  of  melancholy,  absolutely  mute,  patella  reflexes 
absent.  Pupils  dilated,  cardinal  tongue,  strings  of  saliva  extends 
from  upper  to  lower  Jfeeth  when  mouth  is  opened.  Takes  no  interest 
in  surroundings  or  conversation,  thus  being  without  insight.  Rem- 
nants of  pellagrous  eruption  on  hands  and  elbows ;  has  always  eaten 
bought  meal. 


215 

Hospital  record:  Upon  admission  was  restless,  deluded,  probably 
subject  to  hallucinaiions,  required  constant  watching.  Full  tub  baths 
had  a  soothing  effect  for  a  time,  following  the  baths,  on  the  nervous 
manifestations. 

June  14th  was  nervous,  restless,  noisy  and  deluded. 

June  15th,  same  condition  except  stools  frequent  and  involuntary. 

June  1 6th,  involuntary  stools,  but  quiet. 

June  17th,  refused  food,  quiet. 

June   1 8th,  rested  quietly.     Bed  sore. 

June  19th,  fairly  quiet  day,  temperature  and  pulse  both  elevated 
and  limbs  slightly  rigid  and  tremulous,  low  muttering  delirium,  con- 
tinuous rectal  irrigation  was  commenced.  The  temperature  gradu- 
ally rose  and  the  neuro  muscidar  manifestations  became  more  ac- 
centuated until  the  condition  reminded  one  of  strychnine  poisoning. 
Evidence  of  intense  toxaemia  were  present,  low  muttering  delirium, 
carphology,  subsultus  and  dry  tongue.  All  of  these  symptoms  con- 
tinued with  increasing  severity  until  the  morning  of  the  24th,  when 
death  closed  the  scene. 

Case  3  :  Before  taking  up  the  anamnesis  of  this  case  it  will  be  nec- 
essary to  review  the  family  history;  although  the  patients  were  not 
seen  by  me. 

L.  C,  male,  age  11,  parents  living,  father  being  a  miller.  One 
sister  died  three  years  ago  of  pellagra  at  14  years,  and  brother  of 
same  disease  at  11  years,  four  years  ago.  Both  died  in  August. 
The  two  fatal  cases  having  developed  the  disease  in  their  fifth  and 
fourth  years  respectively.  The  disease  manifested  itself  in  the 
spring,  and  was  supposed  to  be  ivy  poisoning.  Remissions  and 
exacerbations  occurred  during  the  spring  and  summer,  and  in  win- 
ter the  dermatitis  and  diarrhoea  were  entirely  absent.  The  disease 
increased  in  severity  for  six  years  in  the  case  of  the  boy  till  finally, 
after  being  unable  to  walk  for  two  months,  he  was  confined  to  bed 
four  months,  and  following  one  month  of  excessive  vomiting  and 
diarrhoea,  died  of  exhaustion.  On  several  occasions  he  vomited 
dark  clotted  blood.  The  girl  had  the  disease  mildly  at  first,  S9re 
mouth,  diarrhoea,  and  eruption  on  hands  and  feet.  With  her  the 
disease  lasted  nine  years.  She  had  vertigo,  burning  in  stomach,  pain 
in  back  of  neck  and  between  shoulders,  head  drawn  back,  high  fever, 
was  treated  for  "spinal  trouble"  and  "hysteria."  There  was  a  ten- 
dency to  stagger  and  fall  backwards  after  any  exertion.  This  was  a 
striking  feature  of  the  case  for  the  last  two  years  of  her  life.  There 
was  no  vomiting  till  shortly  before  death,  nor  was  the  diarrhoea  so 


2l6 

severe  as  in  her  brother's  case.  In  April,  1906,  she  complained  of 
intense  burning  in  stomach  "like  she  was  burning  up."  The  erup- 
tion, stomatitis  and  diarrhea  then  appeared,  and  she  soon  became 
very  weak  and  was  confined  to  bed  till  August,  when  she  died,  evi- 
dently of  tphoid  pellagra.  For  about  two  weeks  before  death  she 
had  convulsions  with  increasing  frequency.  Hemorrhages  from 
bowels.  There  was  opisthotonos  arms  and  legs  rigid,  mouth  quite 
tremulous  "like  she  was  chewing,"  sublustus  marked,  and  for  the 
last  week  of  life,  temperature  was  "very  high." 

These  histories  are  obtained  from  the  father  and  mother.  Fur- 
thermore, the  father  stated,  that  it  was  the  habit  of  these  children  as 
soon  as  they  were  old  enough  to  accompany  him.  to  his  work,  when 
playing  about  the  mill-house,  frequently  to  eat  raw  meal  hot  from  the 
rock.  The  first  year  that  either  of  the  children  was  affected,  he 
remembers  that  the  local  corn  crop  was  practically  a  failure  the 
previous  year,  and  that  he  ground  a  great  deal  of  shipped  corn 
that  he  knew  was  damaged,  spoiled  or  rotten. 

So  far  as  can  be  learned  neither  the  father  nor  the  mother  has 
at  any  time  had  the  symptoms  of  a  disease  that  suggests  pellagra. 
It  should  also  be  recorded  that  the  disease  was  not  recognized  as 
pellagra  during  the  lives  of  these  two  children.  Furthermore,  the 
father  states  that  so  far  as  possible  he  selected  the  best  corn  only 
for  his  family  use.  This  may  explain  why  the  parents  escaped, 
while  the  children  ate  raw  meal  of  any  sort  and  contracted  pel- 
lagra. 

L.  C,  male,  age  11,  brother  of  the  above  described  cases.  He 
developed  the  disease  at  two  years  of  age.  The  pellagrous  syndrome, 
dermatitis,  stomatitis  and  diarrhoea  appearing  every  year  in  the 
spring.  The  diarrhoea  has  never  been  severe,  three  or  four  actions 
a  day  in  the  early  spring  months.  He  has  a  tendency  to  stoop  for- 
ward, and  when  tired  falls  down  on  his  all-fours. 

Physical  Examination:  A  fairly  well  nourished,  but  small  boy, 
mentality  low  for  his  age,  pupils  moderately  dilated  but  not  as 
much  as  they  were  in  June.  Patella  reflexes  aggravated.  Not  men- 
tally depressed.  Sometimes  plays  as  other  children  do,  and  again 
is  unusually  quiet. 

The  accompanying  photograph  will  show  the  extent  of  the  erup- 
tion. 

Case  4:  Miss  C.  C.  S.,  age  25,  white  woman.  Aunt  on  mother's 
side  had  "nervous  spells."    Family  history  otherwise  negative. 

Previous  health  good.     Was  taken  sick  in  INIarch,   1904.     First 


ILLUSTRATION  NO.  IV. 

Case   III.,    S.    C. — Showing   pellagrous   eruption   on   face.      Note   line   of 
demarkation  on  neck. 


217 

symptom  was  indigestion,  diarrhoea  and  burning  pain  in  stomach 
and  "smothering  feeling."  Could  not  stand  to  look  at  water  or  hear 
it  splash,  as  it  would  make  her  very  nervous,  blind  and  dizzy,  and 
cause  her  to  have  shortness  of  breath.  Was  very  thirsty,  but  was 
almost  prohibited  from  drinking,  by  the  sensation  produced  by  the 
sight  of  water,  and  only  when  thirst  could  be  endured  no  longer 
would  she  force  herself  to  swallow  a  few  mouthfuls.  Mouth  was 
very  red  and  sore,  with  quantities  of  thick  saliva. 

Eruption. came  on  hands  and  arms  about  two  months  after  onset 
of  diarrhoea,  and  one  month  later  came  on  face.  These  symptoms 
continued  until  September,  when  improvement  set  in  and  she 
thought  she  was  well. 

In  spring  of  1905  there  was  a  repetition  of  all  the  symptoms,  but 
more  severe — well  during  winter. 

In  spring,  1906,  light  attack,  except  mental  depression  was  more 
pronounced. 

These  exacerbations  and  remissions  have  occurred  each  year 
since.  In  1907  the  diarrhoea  was  more  severe  than  at  any  other 
period  of  the  disease,  the  bov/els  acting  as  often  as  twenty  times  a 
day,  for  days  at  a  time. 

March,  1908,  all  symptoms  returned,  eruption  being  more  exten- 
sive than  any  previous  attack.  Mental  depression  marked,  vertigo 
severe.  Had  a  desire  "to  run  and  go  away  hundreds  of  miles." 
Would  be  unable  to  sleep  at  night,  and  would  get  up  and  walk 
around  house  for  hours  and  not  stop  until  forced  to  do  so  from 
exhaustion. 

Seen  by  me  July  i6th,  1908, 

Examination :  Emaciated  woman,  apparently  35  years  old.  Heart 
and  lungs  normal,  abdomen  negative,  except  for  slight  meteorism. 
Radical  arteries  palpable.  Pellagrous  eruption  on  hands,  arms, 
elbows  and  below  elbows,  neck,  face  and  chest.  The  extensive  dis- 
tribution in  this  case  was  due  to  her  wearing  a  very  thin  shirtwaist ; 
although  extensive  the  eruption  was  symmetrical.  Tongue  a  cardi- 
nal red  and  bald,  abundance  of  thick  saliva.  Pupils  widely  dilated, 
reflexes  exaggerated,  marked  tenderness  in  mid  dorsal  region. 
Answers  questions  intelligently  and  promptly.  She  was  advised 
to  give  up  all  products  of  corn  in  diet.     No  medicine  prescribed. 

Was  seen  in  May,  1909,  was  then  the  picture  of  health  and  had 
gained  25  pounds.    Bland's  pills  with  atoxyl  prescribed. 

On  May  20th  a  slight  diarrhoea  set  in  and  two  weeks  later  the 
eruption  appeared. 


2l8 

The  following  report  was  received  from  her  September  29th: 
Entirely  free  of  eruption,  disappeared  two  weeks  ago,  has  been  very 
slight  this  year.  Has  kept  out  of  sun,  every  time  she  went  out  the 
eruption  would  come  back.  Bowels  have  not  been  loose,  rather  con- 
stipated. Mouth  has  been  very  sore,  as  though  "burnt  with  lye." 
Troubled  with  sleeplessness,  complains  of  her  stomach  and  feeling 
weak;  though  for  the  last  two  weeks  that  has  been  relieved  to  a 
great  extent.  Some  months  ago  had  a  very  profuse  "flow"  lasting 
three  weeks,  "almost  a  hemorrhage." 


DISCUSSION  ON  THE  PAPER  OF  DR.  WATSON 

Dr.  C.  L.  Minor^  Asheville,  N.  C. :  In  considering  the  symptoma- 
tology Dr.  Watson  failed  to  mention  one  symptom  which  I  regard  as 
of  the  greatest  value,  namely,  the  peculiar  slimy  greenish  stools  with 
a  peculiar,  and,  I  believe  characteristic,  sickly  sweet  odor  which  our 
nurses  have  noted  in  all  the  cases. 


219 


AMEBAE  IN  THE  STOOLS  OF  PELLAGRINS 

WILLIAM  ALLENj  M.  D. 

CHABLOTTE,  N.  C. 

Amebiasis  is  endemic  in  Mecklenburg  County,  North  Carolina, 
and  I  believe  it  is  very  widespread  throughout  the  South.  In  Char- 
lotte our  death  rate  from  amebiasis  constantly  exceeds  that  from 
typhoid  fever.  Hence  in  a  series  of  cases  of  any  disease  we  should 
expect  to  find  amebiasis  as  a  complication  in  a  certain  per  cent,  of 
them.    That  this  is  true  of  pellagra  is  shown  by  the  following  case : 

Mr.  S.  O.,  white,  male,  age  69,  was  reported^  in  February,  1909, 
as  a  case  of  amebiasis.  Two  weeks  rest  in  bed,  with  liquid  diet, 
large  doses  of  ipecac  and  colonic  irrigations  reduced  the  number  of 
stools  from  12  to  6  daily.  During  this  time  the  occurrence  of  blood 
in  the  stools  became  rare  and  amebse  entirely  disappeared.  But  the 
patient  still  averaged  six  stools  a  day.  Some  three  weeks  later  skin 
lesions  pathognomonic  of  pellagra  appeared  and  explained  the  dis- 
appointing results  obtained  by  our  previous  treatment. 

The  high  percentage  (5  out  of  7  Pellagrins  examined)  that  show 
monads  in  their  stools  would  indicate  that  these  cases  are  unusually 
liable  to  intestinal  parasitic  infection. 

The  finding  of  amebse  in  the  stools  is  variously  interpreted  by 
different  observers.  Probably  pathogenic  amebse  at  times  inhabit 
the  lumen  of  the  bowel  without  attacking  the  mucous  membrane ; 
and  there  are  probably  species  of  amebse  inhabiting  the  lumen  of 
the  bowel  which  are  unable  to  attack  the  mucous  membrane, 
although  Musgrave  and  Clegg^  deny  this.  Quinke  and  Roos^ 
describe  three  (3)  species  inhabiting  the  human  intestine,  two  of 
which  they  consider  pathogenic.  Celli  and  Fiocca^  describe  five  (5) 
species,  all  presumably  pathogenic.  But  Calkins*  very  clearly  points 
out  that  a  species  of  amebse  can  be  identified  only  by  following  out 
its  entire  life  cycle.  This  the  average  practitioner  is  not  qualified  to 
do.  However,  two  species  occurring  in  the  human  intestine  have 
been  thus  carefully  studied  by  Shaudinn^  and  named  by  him 
entameba  coli  and  entameba  histolytica. 

In  examining  stools  containing  amebse  we  should  expect  to  see 
all  shapes  and  sizes  of  amebse  from  budding  youth  to  encysted  old 
age.  Hence  it  is  impossible,  particularly  in  the  case  of  small  amebae, 
to  assign  them  to  any  given  species  or  to  say  whether  or  not  they  are 


220 

patheogenic,  without  tedious  experimental  work.  However,  I  wish 
to  record,  merely  as  a  matter  of  interest,  the  finding  of  small  ameboid 
organisms  in  the  stools  of  four  out  of  five  cases  of  pellagra  that  have 
been  carefully  studied.  These  organisms  measure  .010.01 5mm  in 
diameter,  or  a  little  larger  than  a  red  blood  corpuscle.  Their 
size  necessitated  a  magnification  of  600  diameters  or  more 
for  satisfactory  observation.  There  were  no  larger  amebse  present; 
no  nucleus,  vacuoles,  or  included  particles  could  be  made  out.  The 
cytoplasm  was  semi-transparent,  finely  granular  and  lighter  than 
that  of  a  red  blood  corpuscle.  The  pseudopodia  consisted  of  ectosarc 
of  clearer  material  than  the  cell  cytoplasm.  Whether  or  not  these 
organisms  belong  to  the  amebae  family,  or  are  monads  in  the  pre- 
fusion  stage,®  or  are  ameboid  cells  from  some  other  source  I  cannot 
say. 

The  danger  of  mistaking  amebiasis  for  pellagra  and  vice-versa 
is  considerable.  For  example,  a  few  weeks  ago  I  studied  an  epi- 
demic of  amebiasis  in  which  all  the  cases  showed  sore  m.ouths  and 
most  of  them  diarrhoea.  When  the  first  case  was  seen  a  tentative 
diagnosis  of  pellagra  was  made.  As  soon  as  it  became  evident  that 
the  trouble  was  epidemic  the  stools  were  examined  and  entameba 
histolytica  demonstrated.  Conversely  a  few  days  ago  a  case  was 
brought  to  me  to  confirm  the  diagnosis  of  pellagra.  There  was  a 
slimy  fissured  tongue  and  rough  thickened  skin  over  the  ankles, 
moderate  diarrhoea  and  neurasthenia.  On  closer  examination  the 
skin  lesion  was  found  to  be  non-pigmented  and  itched,  as  dis- 
tinguished from  the  burning  or  tingling  of  pellagra.  This  was  con- 
sidered a  dry  eczema.  A  differential  blood  count  showed  eosino- 
philia  8  per  cent.,  which  is  almost  invariably  pathognomonic  of  para- 
sites in  this  latitude. 

The  symptoms  of  pellagra  and  amebiasis  are  at  times  so  much 
alike  that  it  is  sometimes  very  difficult  to  tell  with  which  disease  we 
are  dealing.  I  have  before  called  attention  to  the  fact  that  in  both 
of  these  conditions  the  appearance  of  the  mouth  and  tongue  are 
similar.^  In  both  there  are  all  grades  of  diarrhoea;  in  amebiasis, 
depression  and  neurasthenia  often  entirely  overshadow  the  other 
symptoms  of  intestinal  parasitism'^ ;  in  both  there  may  be  marked 
emaciation.  As  long  as  the  etiology  of  pellagra  is  unknown  the 
treatment  must  necessarily  be  largely  symptomatic.  Therefore  we 
are  not  justified  in  diagnosing  and  treating  as  pellagra  cases  that 
show  only  sore  mouth,  diarrhoea,  emaciation  and  melancholia  until 


221 

amebiasis  has  first  been  excluded.     This  is  readily  accomplished  by 
a  differential  blood  count  and  an  examination  of  the  feces. 

SUMMARY. 

1st.     Pellagra  is  often  complicated  by  amebiasis. 

2d.  Many  varieties  of  amebae  may  be  found  in  the  feces  of  pella- 
grins. 

3d.  Pellagra  is  liable  to  be  mistaken  for  amebiasis  and  vice- 
versa. 

4th.  In  diagnosing  and  treating  pellagra  in  the  absence  of 
pathognomonic  skin  lesions  or  grave  mental  symptoms  it  is  first 
necessary  to  exclude  amebiasis. 

REFERENCES. 

1.  Allan.    Old  Dominion  Journal  of  Medicine  and  Surgery,  Vol.  8,  No.  5,  May  1909. 

2.  Braun.     Animal  Parasites  of  Man.     Page  36. 

3.  Manson.     Tropical  Diseases.     Page  440. 

4.  Calkins — Protozoology.     Page  295. 

5.  Idem.     Page  298. 

6.  Idem.    Page  154. 

7.  Allan.     So.  Med.  Journal.  November,  1909. 


DISCUSSION  ON  THE  PAPER  OF  DR.  ALLEN 

Capt.  H.  J.  Nichols,  U.  S.  Army:  Dr.  Allen's  paper  is  very- 
important  in  that  he  raises  the  point  of  the  diagnosis  of  pellagra 
without  skin  symptoms.  For  scientific  purposes  in  the  study  of  our 
cases  we  ought  to  eliminate  those  which  do  not  show  skin  symp- 
toms. It  may  occasionally  be  necessary  to  diagnose  pellagra  without 
skin  symptoms,  but  it  is  not  safe  at  this  stage  of  our  knowledge  of 
this  disease,  because  there  are  so  many  other  diseases,  especially 
sprue,  which  follow  somewhat  the  same  course  which  Dr.  Allen 
referred  to  m  cases  of  amoebic  dysentery.  Cases  of  sprue  can  be 
easily  stretched  into  a  diagnosis  of  pellagra,  if  we  do  not  insist  on 
skin  symptoms.  This  paper  has  a  bearing  also  upon  the  mortality 
of  the  disease.  There  are  a  great  many  deaths  attributed  to  pellagra, 
which,  in  my  opinion,  ought  to  be  ascribed  to  other  diseases,  espe- 
cially dysentery.  We  should  always  endeavor  to  determine  how 
much  other  disease  exists  in  our  pellagrous  patients. 

Dr.  Allen  (closing  the  discussion)  :  At  present  our  health 
authorities  in  the  South  do  not  recognize  amoebic  dysentery  as  a 
reportable  disease.  In  North  Carolina,  for  instance,  there  are  no 
records  of  deaths  from  amoebic  dysentery,  and  while  we  see  a  great 
deal  of  amoebiosis  and  it  is  invariably  reported  as  something  else. 


222 


RESULTS  OF  STOMACH  ANALYSES  IN  PELLAGRA 

W.  O.   NISBET^  M.  D. 

CHAELOTTE,    N.    C. 

I  desire  to  report  results  of  the  analysis  of  stomach  contents  of  ten 
cases  of  pellagra.  All  of  the  cases  were  given  the  Ewald-Boas 
breakfast  of  one  roll  and  one  and  a  half  glasses  of  water  and  con- 
tents were  removed  by  tube  one  hour  after  ingestion.  The 'acidity 
was  estimated  by  Topfer's  method  of  titration.  A  detailed  account 
of  the  cases  will  not  be  given ;  only  the  stage  of  the  disease  and 
the  points  bearing  on  the  stomach  secretion  will  be  mentioned.  My 
experience  is  limited  to  twenty-five  cases  of  pellagra  and  in  only  ten 
of  this  twenty-five  did  I  succeed  in  getting  test  meals. 

Case  I :  Miss  W.,  native  of  Alabama,  age  29.  History  of  diarrhoea 
in  spring  of  1907.  I  saw  patient  first  in  September,  1908,  and  found 
present  hand  and  wrist  eczema,  bald  tongue,  burning  in  stomach  and 
diarrhoea,  anal  excoriations,  slow  mental  action,  despondency,  but 
with  reflexes  about  normal ;  emaciation  to  an  extreme  degree.  Only 
one  test  was  made  of  stomach  contents  and  showed  HCl,  O;  total 
acidity,  30;  ferments  not  estimated;  mucus  in  excess.  Bile  was 
present  during  the  periods  of  severe  vomiting.  Motility  not  tested 
Patient  died  October,   1908. 

Case  2 :  Miss  C,  age  26,  native  of  South  Carolina.  First  seen  in 
September,  1908;  gastro-intestinal  and  mental  symptoms  marked 
and  eczema  beginning  on  knuckles.  Patient  gave  history  sore 
mouth,  nausea  and  diarrhoea  in  the  spring  of  the  preceding  year. 
Analysis  stomach  contents  HCl,  4;  total  acidity,  28;  mucus,  in 
excess;  ferments,  coagulation  of  milk  delayed.  Motility  not  tested. 
History  of  presence  of  bile  during  severe  vomiting.  Died  six  weeks 
later. 

Case  3:  Mrs.  R.,  age  35;  native  of  South  Carolina.  Had  been 
very  nervous  for  twelve  months,  and  had  raw  mouth  and  tongue  in 
the  past  spring.  Saw  first  August,  1908,  and  presented  character- 
istic gastro-intestinal  signs  with  staggering  gait,  but  no  hand 
eczema;  analysis  stomach  contents  HCl,  35;  total  acidity,  80;  fer- 
ments normal ;  mucus,  no  excess ;  bile  present ;  motility,  stomach 
empty  two  and  half  hours  after  test-breakfast.  This  patient  got  bet- 
ter during  winter,  but  had  a  return  of  symptoms  in  following  April ; 
still  no  hand  eruption.     At  this  time  a  second  stomach  analysis 


223 

showed  HCl,  lo;  total  acidity,  40;  mucus,  no  excess.  The  eczema 
appeared  on  hands  and  wrists  in  the  following  August.  An  analysis 
at  this  time  gave:  HCl,  4;  total  acidity,  28;  mucus,  no  excess;  bile 
absent ;  motility,  normal.    Patient  still  living. 

Case  4:  J.  E.,  adult  male,  age  31 ;  native  of  North  Carolina.  His- 
tory of  mild  alcoholism  and  of  spring  diarrhoeal  attacks  for  several 
years ;  mouth,  stomach,  bowel  and  cord  signs  present  when  seen  in 
August,  1908.  Analysis:  HCl,  8;  total  acidity,  33;  mucus,  in 
excess;  ferments,  diminished;  motility,  normal;  bile  present  during 
periods  of  vomiting.  There  was  improvement  during  winter,  but  in 
May  symptoms  returned  in  increased  severity  and  with  the  presence 
of  the  typical  eczema  of  hands,  arms  and  elbows. .  Analysis  at  this 
time  gave  following:  HCl,  o;  total  acidity,  24;  mucus,  in  excess; 
motility,  normal.     Patient  died  the  following  September. 

Case  5 :  Mrs.  W.,  age  36 ;  native  of  North  Carolina.  Eczema  and 
gastro-intestinal  symptoms,  marked ;  locomotion  and  reflexes,  nor- 
mal;  mental  action,  sluggish.  Result  of  analysis  HCi,  4;  T.  A.,  18; 
mucus,  no  excess ;  motility,  normal ;  ferments,  normal.  Patent  im- 
proved under  arsenic,  but  had  a  mild  recurrence  the  following 
spring. 

Case  6:  Mrs.  P.,  age  34;  native  of  North  Carolina.  Gastro-intes- 
tinal symptoms,  with  insomnia  and  vertigo  appeared  in  fall  of  1908. 
Analysis  at  this  time  gave:  HQ,  24;  T.  A.,  56;  ferments,  normal; 
motility,  normal ;  mucus,  excess.  In  June,  1908,  the  above  men- 
tioned symptoms  returned  in  acute  form  along  with  decided  hand 
eruption.  Specimen  of  contents  at  this  time  gave  no  reaction  for 
HCl,  but  there  was  excess  of  mucus.  Patient  died  six  weeks  later. 
Case  7:  ]\Irs.  E.,  age  38;  native  of  North  Carolina.  Sore  mouth, 
burning  stomach  and  periodical  diarrhoea  appeared  in  September, 
1907.  Analysis  at  this  time  gave :  HCi,  39;  T.  A.,  76;  mucus,  not  in 
excess ;  motility,  normal.  Patient  improved  under  arsenic  and  cold 
weather,  but  in  April  had  a  return  of  symptoms,  with  the  appear- 
ance of  hand  eruption  in  addition.  Analysis  :  HCl,  20 ;  T.  A.,  42 ; 
mucus,  no  excess ;  motility,  normal.  A  third  analysis  in  October 
gave  result:  HCl,  8;  T.  A.,  22;  mucus,  in  excess;  motility,  normal. 
Case  8 :  Mrs.  M.,  age  37 ;  native  of  North  Carolina.  Sore  mouth 
and  gastro-intestinal  signs  first  appeared  in  April,  1909.  Insomnia 
and  despondency  at  times  for  two  years.  In  August,  in  addition  to 
above  symptoms,  began  to  walk  unsteadily  and  noted  also  the  appear- 
ance of  "sunburn"  on  knuckles  and  back  of  hand.     Analysis  at  this 


224 

Stage  showed:  HQ,  19;  T.  A.,  40;  ferments,  normal;  mucus,  no 
excess. 

Case  9:  Mrs.  B.,  age,  29;  native  of  North  Carolina.  Hereditary 
specific  history.  Nursed  a  sister  who  died  of  pellagra.  Six  months 
ago  developed  red  tongue,  distress  in  stomach  and  nervousness, 
with  despondency.  At  present  has  still  the  above  symptoms  and 
beginning  eruption  on  knuckles.  Analysis:  HCl,  20;  T.  A.,  50; 
mucus,  no  excess ;  motility,  normal.  This  case  may  clear  up  under 
specific  treatment  and  prove  not  pellagra. 

Case  10:  Mrs.  M.,  age  39;  native  of  North  Carolina.  Has  had 
diarrhoea  and  indigestion  for  two  years.  In  April  of  this  year 
developed  marked  diarrhoea,  gastric  distress  and  a  red  mouth  and 
tongue  and  case  was  pronounced  pellagra  by  consulting  physicians. 
At  present  time  she  is  a  typical  pellagrin.  Analysis :  No  HCl,  nor 
total  acidity;  excess  of  mucus;  bile  present. 

SUMMARY. 

Cases  I,  2,  4,  6,  7,  10  show  a  marked  diminution  in  the  acid  fac- 
tors of  the  gastric  juice  in  the  late  stage  of  the  disease. 

Cases  I,  2,  4,  5,  10  show  excess  of  mucus  during  the  pellagrous 
periods. 

Cases  3,  4,  5,  6,  8,  9  show  normal  motility,  while  in  1,2,  10  motility 
test  was  not  made. 

Cases  I,  2,  4,  10  show  presence  of  bile  during  severe  vomiting 
periods. 

This  series  of  cases  is  too  small  to  allow  us  to  draw  any  definite 
conclusions,  but  the  indications  are  that  in  pellagra,  as  in  all  adyna- 
mic and  asthenic  diseases,  the  HCl  and  ferments  of  gastric  juice 
progressively  diminish. 


225 


'PERSONAL  OBSERVATIONS  ON  PELLAGRA 

T.  W.   L.  BAILEY,  M.  D. 

CLINTON^    S.    C. 

Mr.  President  and  Gentlemen  of  the  Convention :  It  is  not  my 
purpose  to  take  up  but  a  small  bit  of  your  valuable  time  in  reporting 
to  you  the  limited  experience  I  have  had  with  pellagra. 

I  wish  only  to  give  you  a  synopsis  of  the  most  striking  symptoms 
as  they  occurred  to  me.  Beginning  with  Case  i,  which  I  observed 
about  five  years  ago,  at  that  time  the  correct  diagnosis  was  not  made, 
the  symptoms  so  prominent  in  that  case  I  have  seen  in  almost  all  the 
cases  since  then.  The  cases  usually  begin  with  an  acute  diarrhoea; 
that  is,  the  diarrhoea  is  the  first  symptom  the  physician  is  called 
upon  to  treat.  This  diarrhoea  is  very  persistent  and  does  not  yield  to 
ordinary  medication  that  usually  is  given  in  a  deranged  bowels  that 
is  caused  from  errors  in  diet.  The  stools  are  similar  to  an  acute 
diarrhoea,  but  persists  for  a  longer  period  of  time  and  does  not 
usually  assume  the  catarrhal  or  dysentery  type  that  follows  an  ordin- 
ary spring  diarrhoea.  The  diarrhoea  persists  for  several  weeks, 
having  from  12  to  20  stools  daily.  In  a  few  weeks  after  the  onset 
of  the  disease  we  have  an  acute  stomatitis,  a  smooth,  plain  inflamed 
condition  of  the  mucous  membrane  of  the  mouth,  lips,  ducal  mem- 
brane, also  extending  down  in  the  eosophagus,  sometimes  a  gastritis. 
I  observed  this  inflammation  in  the  vagina  and  anus  in  one  of  my 
patients.  The  vaginitis  was  a  source  of  great  annoyance,  producing 
an  irritation  and  caused  pain  on  passing  water.  There  is  a  peculiar 
but  a  typical  eruption  or  erythema  develops  symmetrically  on  the 
back  of  the  hands,  this  extends  up  the  arms  as  far  as  the  sleeve 
reached.  This  eruption,  in  all  my  cases,  did  not  have  a  tendency  to 
spread  around  on  the  flexor  side  of  the  arm  except  in  one  case  I 
saw  recently  in  consultation. 

I  may  say  the  eruption  has  a  characteristic  different  from  any 
eczema  that  I  have  seen.  It  first  usually  occurs  suddenly  as  a  sun- 
burn, on  the  back  of  both  hands,  very  red  and  almost  the  appear- 
ance of  a  blister.  This  erythema  or  eczema  does  not  cause  pain  or 
itching.  After  a  few  days  the  hand  shows  a  peeling  or  exfoliation 
of  the  skin,  then  you  have  a  scaly  and  irregular  appearance  of  the 
skin.     This  scaly  condition  goes  to  a  mark  that  would  outline  the 

15— p.  C. 


226 

beginning  of  the  palmar  surface  of  the  hands.  At  this  Hne  it  pre- 
sents a  stained  appearance,  as  the  patient  had  stained  them  walnut 
or  persimmon  stain.    This  discoloration  cannot  be  washed  off. 

I  noticed  in  a  case  that  is  two  or  more  years'  standing  there  is  a 
deep  fissure,  only  on  each  of  the  index  fingers  and  at  the  first  phalanx. 
There  are  many  small  cracks  or  fissures  on  the  backs  of  the  hand, 
but  the  index  finger  fissure  is  very  prominent.  The  eruption  is  not 
found  under  the  clothing.  You  find  a  symmetrical  patch  on  the 
sides  of  the  neck,  the  molar  bones  or  cheek,  and  sometimes  the  tip 
of  the  nose.  The  tongue,  as  the  case  progresses  in  all  the  cases  I 
have  seen,  is  very  typical,  that  is  all  tongues  look  so  much  alike. 
The  tongue  is  highly  red,  not  a  scarlet  tongue  appearance,  not  the 
prominent  papillae,  but  a  clean,  slick,  red  tongue  with  a  venous  or 
slightly  purple  hue,  and  this  characteristic  does  not  vary  very  much 
for  months  or  perhaps  through  the  entire  course  of  the  disease.  I 
have  not  found  a  coated  or  furred  tongue  with  my  patients.  It  is  a 
disease  of  chronic  persistent  gastric  disturbance;  the  patient  soon 
learns  that  he  has  to  be  careful  about  his  diet,  and,  of  course,  in 
some  cases  the  appetite  is  inordinate,  and  frequently  take  food  that 
disagrees  and  provokes  an  exacerbation  of  the  symptoms.  I  have 
one  patient  who  has  an  insatiable  appetite  for  corn  bread,  and  at 
times  would  take  small  pieces  of  corn  bread,  but  invariably  would 
follow  an  aggravated  diarrhoea  and  eczema.  Other  articles  of  hard 
food  to  digest  would  also  provoke  the  same  symptoms. 

Progressive  emaciation,  though  slow  in  most  cases,  is  always 
noticed.  This  is  a  feverless  disease  per  se.  I  have  never  found  the 
patient  with  fever  unless  you  had  a  plain  complication  with  it. 

I  have  been  astonished  to  find  the  heart's  action  so  nearly  perfect 
in  this  disease.  The  rate  has  persisted  in  remaining  practically 
normal,  even  after  marked  emaciation  had  developed. 

Nervous  Symptoms :  Insomnia  is  the  most  prominent  symptom 
that  develops  first  of  the  nervous  phenomena,  and  this  comes  with 
the  most  of  the  patients  and  early  with  the  disease.  Latterly  hallu- 
cinations on  various  subjects  occur.  A  case  under  my  care  last  year, 
after  the  typical  eruption  had  subsided,  had  a  severe  attack  of  hallu- 
icinations  and  continued  for  a  week,  and  I  may  say  I  was  greatly 
alarmed  over  this  case  as  to  recovery ;  is  now  in  very  good  apparent 
health,  able  to  attend  to  domestic  duties,  with  no  return  of  eczema 
or  glossitis,  though  she  lives  in  dread  or  apprehension,  and  is  more 
or  less  nervous,  has  poor  digestion  and  has  the  hyperasthetic  knee 
jerk.    I  am  waiting  with  a  deal  of  interest  to  see  the  outcome  of  this 


227 

case.  The  case  I  had  five  years  ago  developed  locomotor  ataxia  and 
acute  insanity  and  died. 

Most  of  my  patients  develop  a  careless  way  and  present  a  dejected 
or  despaired  appearance. 

All  the  patients  I  have  observed  are  past  30  years  old.  Have  had 
four  females  and  two  males — all  white  except  one  colored  female. 

Now,  just  a  word  of  synopsis  : 

I  St.  The  acute  uncontrollable  diarrhoea  and  its  persistence. 

2nd.  Salivation  with  stomatitis  and  involving  the  eosophagus,  the 
characteristic  slick  red  tongue  that  does  not  coat. 

3rd.  One  case  of  vaginitis  and  inflamed  anus. 

4th.  The  peculiar  eruption  on  back  of  hands,  sides  of  neck,  both 
cheeks  and  sometimes  tip  of  the  nose. 

5th.  The  feverless  disease. 

6th.  The  hyperasthetic  knee  jerk  occurring  primarily  in  all  cases, 
which  should  always  be  examined. 

7th.  Insomnia,  hallucinations  and  acute  insanity.  One  of  my 
cases  developed  locomotor  ataxia  and  insanity. 


228 


FURTHER     OBSERVATIONS      ON      PELLAGRA     WITH 
POINTS  ON  PROGNOSIS 

JAMES   H.   RANDOLPH,   M.   D.,  AND  RALPH   N.   GREEN,   M.   D. 
Florida   Hospital   for   Indigent   Insane 

CHATTAHOOCHEE,    FLA. 

Several  years  ago  there  came  to  a  young  physician  a  man  who 
sought  advice  for  relief  from  a  skin  disease  with  which  he  had  been 
afflicted  for  a  number  of  years.  The  patient  was  beyond  the  middle 
age  of  life  and  was  noted  for  his  eccentricities  and  slothful  habits. 
Among  the  latter  Avas  a  recently  acquired  taste  for  alcoholic  liquors ; 
and,  being  a  patriotic  citizen,  he  adopted  the  favorite  beverage  of  the 
community  in  which  he  lived,  namely,  corn  whiskey.  He  rapidly 
passed  from  a  state  of  comparative  financial  security  to  one  of  want 
for  the  everyday  necessities  of  life ;  and  upon  examination  presented 
an  extremely  poor  physique.  The  skin  disease  manifested  itself  in 
the  form  of  a  rather  brilliant  erythema,  involving  first  the  hands  and 
face,  and  later  the  extremities.  The  sun's  rays  seemed  to  aggravate 
the  case,  and  hence  the  usual  agricultural  pursuits  upon  which  the 
man  depended  for  support  had  to  be  abandoned  early  in  the  farming 
season.  He  was  given  an  ointment  consisting  largely  of  iodide  of 
starch  and  zinc  oxide,  and  advised  to  suppress  his  bacchanaliarr 
desires  and  limit  his  epicurean  tendencies  to  the  popular  Florida  diet 
of  white  bacon,  hominy  and  corn  bread,  and,  in  addition,  to  spend 
some  weeks  in  frequent  bathing  at  the  Hampton  Sulphur  Springs, 
of  Taylor  County,  Florida.  This  advice  was  followed  religiously, 
and  as  the  fall  season  approached  the  patient  returned  to  his  home 
apparently  much  improved.  During  the  early  winter  months,  how- 
ever, the  poor  fellow  became  melancholy,  and  after  a  bitter  quarrel 
with  his  brother,  which  came  near  being  a  tragedy,  ended  his  life 
by  committing  suicide. 

Today  the  doctor  who  in  his  ignorance  treated  the  case  as  one  of 
vesicular  erythematous  eczema,  realizes  the  true  nature  of  the  malady 
which  he  sought  to  cure ;  and  further  knows  that  his  advice  as  to  diet 
was  little  better  than  adding  fuel  to  the  flames  of  pellagra  already 
lighted  in  his  patient.  And  now,  almost  under  the  shadow  of 
Sand  Mountain,  and  its  famous  beverage  derived  from  maize,  is 
accorded  the  great  honor  of  listening  to  a  discussion  of  this  interest- 


229 

ing  disease  by  a  body  of  most  eminent  pellagrologists,  and  in  the 
few  remarks  to  follow,  as  one  of  the  essayists,  I  lay  no  claim  to  any 
new  or  startling  discoveries,  but  merely  wish  to  report  the  further 
occurrence  of  this  new  disease  at  the  Florida  Hospital  for  Indigent 
Insane,  and  present  the  result  of  our  observations  thereupon  since 
the  original  report  from  one  of  us  (Dr.  Randolph)  at  the  meeting 
of  the  Southern  Medical  Association  in  Atlanta  last  year. 

Incidence :  Since  that  time,  and  for  a  period  of  only  the  last  seven 
months,  during  which  another  of  the  essayists  (Dr.  Green)  has  been 
in  charge  of  the  women's  department  of  the  institution,  there  have 
been  among  a  total  of  eighty-five  women  patients  admitted  (black 
and  white)  eleven  cases  of  pellagra — five  among  the  white  and  six 
among  the  colored.  Among  the  men  during  the  same  period  and 
extending  back  even  further,  to  the  time  of  the  first  report  one  year 
ago,  there  have  been  found  but  two  cases  in  a  total  of  over  one  hun- 
dred and  eighty  admissions  divided  equally  between  white  and 
colored,  and  these  two  cases  were  among  the  negroes.  The  figures 
would  seem  to  support  the  interesting  observations  of  others  that 
there  exists  for  women  a  marked  susceptibility  over  and  above  that 
to  be  found  among  the  men;  and  to  a  less  degree,  also  a  similar 
predisposition  on  the  part  of  the  negroes  as  compared  with  the 
whites.  Out  of  the  total  of  thirteen  cases  here  noted,  all  but  four 
presented  the  classic  symptoms  of  the  disease  upon  admission;  and 
of  the  four  who  subsequently  developed  symptoms,  only  two  had 
been  here  sufficiently  long  to  warrant  the  assumption  that  they  may 
have  contracted  the  disease  within  our  portals. 

Distribution :  The  disease  does  not  seem  to  be  confined  to  any 
one  section  or  locality  in  the  State ;  our  cases  having  been  received 
from  fourteen  dififerent  counties,  scattered  irregularly  through 
Florida  from  one  extreme  to  the  other.  Hillsborough,  Dade,  Duval 
and  Gadsden  Counties  contributing  two  each,  while  Escambia, 
Washington,  Jefferson,  Columbia,  Alachus,  Bradford,  St.  Johns, 
Pasco,  Manatee  and  Desoto  are  represented  by  one  each. 

In  the  social  scale,  the  five  cases  observed  among  the  white  women 
represented  as  many  different  walks  of  life,  from  a  pauper  epileptic 
idiot  to  a  highly  educated  elderly  woman  of  refinement  now  in  a 
stage  of  terminal  dementia,  and  includes  a  farmer's  wife,  a 
mechanic's  wife  and  a  prostitute.  Among  the  colored  women  the 
patients  were  recruited  from  the  turpentine  camps  of  the  State, 
where  there  is  a  notable  absence  of  general  or  personal  hygiene; 
and  one  of  these  cases  had  been  employed  in  packing  leaf  tobacco, 
but  inquiry  revealed  the  fact  that  she  had  long  been  a  simple-minded. 


230 

dissipated  individual,  addicted  to  the  use  of  snuff  and  "nigger  gin." 
With  the  men  the  same  diversity  of  social  conditions  exist  if  the 
cases  formerly  reported  be  taken  into  consideration,  among  which 
were  noted  a  lawyer,  mechanic,  carpenter,  farmer  and  negro  turpen- 
tine laborer. 

The  ages  of  the  patients  that  have  come  under  our  observation 
range  from  that  of  a  child  thirteen  years  old  to  that  of  an  aged 
woman  (also  one  negro  man)  over  eighty  years  of  age;  the  majority, 
however,  being  around  forty. 

Etiological  Factors :  In  all  our  cases  a  history  of  maize  diet  in 
some  form  is  obtainable,  though  not  as  much  importance  seemed  to 
attach  to  this  in  some  as  in  others,  and  in  all  there  were  to  be  found 
contributing  factors,  such  as  alcoholism,  syphilis,  tuberculosis  and 
the  naturally  lowered  vitality  of  old  age  with  or  without  long  con- 
tinued mental  disturbance.  In  the  light  of  our  present  experience 
and  familiarity  with  the  quality  and  nature  of  the  corn  products 
used  in  this  State,  Vv^e  are  inclined  to  believe  that  not  only  may  the 
imported  Western  varieties  of  corn  be  responsible  for  this  condition 
in  our  people,  but  likewise  the  native-grown  crops,  which  have 
greatly  deteriorated  in  later  years  with  the  advent  of  the  thriftless 
negro  farmer  to  replace  the  "old-time"  methods  of  the  intelligent 
planter  in  the  days  "befo  de  wah." 

Symptomatology :  The  symptoms  observed  have  not  differed  in 
our  experience  from  the  usual  classic  description  of  the  disease. 
Depressed  or  melancholic  states  predominate,  with  persecutory  and 
somatic  delusions,  confusion  and  a  marked  tendency  to  burrow  under 
the  bed  clothes,  which  has  been  observed  with  some  of  our  patients. 
Those  cases  which  succumbed  rapidly  developed  a  state  of  profound 
delirium,  facial  rigidity,  mouth  tremors,  exaggerated  reflexes  and 
profuse  diarrhoea;  but  none  showed  the  convulsive  tendencies 
described  by  Lombroso  for  his  "Typhus  Pellagrosus."  We  continue 
to  note  the  occurence  of  the  erythema  in  the  fall  as  well  as  spring 
months,  and  it  would  seem  to  be  even  a  more  constant  feature  in  the 
former  season  than  the  latter.  One  of  the  white  women  presented 
at  first  the  skin  lesion  only  on  the  inner  and  dorsal  surfaces  of  the 
thumb  and  index  finger,  but  more  later  the  eruption  appeared  on  the 
face,  and,  together  with  the  typical  stomatitis  and  gastro-enteritis, 
left  but  little  doubt  in  our  minds  as  to  the  correctness  of  the 
diagnosis.  Dr.  J.  S.  Norman,  clinical  assistant  at  this  institution, 
has  called  attention   to  the  peculiar  mole-skin  appearance   of  the 


231 

epidermis  in  the  negro,  which  he  suggests  may  be  a  precursor  of  the 
later  inflammatory  condition  of  the  hands,  etc. 

The  temperature,  pulse  and  respiration  show  no  great  divergence 
from  the  normal  curve,  except  in  those  cases  in  extremis,  or  com- 
plicated by  myocarditis,  tuberculosis,  etc. 

Repeated  examination  of  stools  has  failed  to  reveal  the  presence 
of  intestinal  parasitic  infection ;  and,  in  connection  with  this,  eosino- 
philia  has  been  notably  absent. 

Pathology:  In  our  cases,  post-mortem  findings  have  been  con- 
siderably marked  by  the  presence  of  advanced  lesions  of  tubercu- 
losis ;  but  the  gross  appearance  in  the  cord  and  brain  is  not  materially 
different  from  that  described  by  other  investigators,  including  the 
glistening  dura,  thickened  pia  and  hard  small  placques  in  the  arach- 
noid, as  mentioned  by  Lombroso,  and  which  have  been  found  with 
striking  uniformity  in  two  of  our  cases.  Sections  from  these  tracts 
have  been  forwarded  to  the  State  laboratory,  but  as  yet  mounted 
specimens  and  microscopic  diagnosis  have  not  had  time  to  reach  us. 

Differential  leucocyte  count  in  two  of  the  women  (apparently 
uncomplicated  cases)  has  been  instituted,  and  would  seem  to  show 
a  preponderance  of  small  mono-nuclears — though  these  investiga- 
tions have  not  as  yet  progressed  sufficiently  to  prove  conclusive. 

Diagnosis :  So  much  has  appeared  in  the  literature  of  the  past 
year  regarding  the  differential  points  in  the  diagnosis  of  this  disease 
that  little  difficulty  should  now  be  experienced  in  its  recognition; 
though  for  the  more  rare  and  obscure  conditions  described  by 
European  writers  as  "False  Pellagra"  and  "Pellagra  sine  Pellagra," 
there  remains  much  for  further  investigation  and  demonstration.  In 
our  own  cases  the  diagnosis  of  pellagra  is  considered  assured  only 
after  the  appearance  of  cardinal  symptoms — diarrhoea,  dermatitis  and 
dementia — as  first  described  in  this  country  by  Dr.  Babcock.  With 
regard  to  the  so-called  pellagra  sine  pellagra  (or  pellagra  without 
the  dermatitis)  we  confess  to  a  grave  doubt  whether  such  a  condition 
has  not  been  mistaken  for  sprue,  which,  with  the  exception  of  the 
skin  lesions,  bears  a  striking  resemblance  to  pellagra  as  noted  in 
a  recent  report  (1908)  to  the  State  Board  of  Health  of  Georgia  by 
Dr.  H.  F.  Harris,  of  Atlanta,  who  thus  adds  to  his  honors  already 
gained  in  researches  upon  pellagra  and  hookworm  disease. 

Course :  Those  cases  which  were  admitted  in  the  advanced  stages 
of  the  disease  succumbed  on  an  average  of  about  ten  days,  while  in 
those  with  apparent  recovery  the  symptoms  were  noted  to  persist 
for  about  thirty  days. 


232 

• 

In  only  one  case  was  there  complete  disappearance  of  all  mental 
symptoms,  and  this  was  in  the  case  of  a  vigorous  white  woman ; 
while  in  those  with  continuance  of  mental  symptoms,  senile  changes 
were  uniformly  present. 

Treatment :  Potassium  iodide  in  combination  with  bichloride  of 
mercury  has  seemed  to  prove  of  benefit  in  controlling  the  number 
of  stools  in  some  cases,  but  would  appear  to  intensify  other 
symptoms. 

Stick  nitrate  of  silver  has  continued  to  prove  the  best  weapon  in 
our  hands  for  combatting  the  obstinate  stomatitis. 

General  tonic  treatment  is  still  used  with  slight  material  benefit. 
Alcohol  in  the  form  of  whiskey  and  combined  with  beechwood 
creosote  has  proved  of  doubtful  efficacy. 

In  extreme  cases  strychnine  in  large  doses  and  combined  with 
digitalin  hypodermatically  has  proven  of  temporary  benefit;  and  in 
one  case  of  extreme  shock  following  bath,  nitroglycerin  was  added  to 
a  degree  of  tolerance  with  must  happy  results.  This  latter  drug  has 
been  regularly  continued  since,  and,  in  view  of  the  rather  prompt 
and  rapid  clearing  of  the  skin  lesions  in  this  case,  (not  forgetting  the 
fact  that  meta  arsenic  carbamide  had  been  previously  administered), 
it  would  appear  that  further  investigations  with  this  drug  in  its  effect 
upon  the  skin  are  warranted. 

Atoxyl  has  been  used  in  doses  of  grains  one-third  each  day, 
increased  to  one  grain  per  diem,  both  hypodermatically  and  by 
mouth,  but  without  any  apparent  benefit.  Recently  one  of  us  (Dr. 
Greene)  has  used  the  drug  in  dosage  of  seven  and  a  half  grains 
hypodermatically,  repeating  the  dose  once  only  upon  the  second  day, 
in  four  cases.  One  of  these,  which  died  two  days  after  the  first  dose, 
was  in  advanced  stages  of  tuberculosis.  Of  the  other  three  all  may 
be  said  to  have  been  improved,  the  erythema  fading  and  the  number 
of  stools  being  reduced  in  all  but  one.  No  toxic  symptoms  were 
noted  in  any,  such  as  amblyopia,  gastric  pain,  etc.,  but,  on  the  other 
hand,  actual  relief  from  previous  and  persistent  nausea  has  been 
observed.  In  the  light  of  our  experience  with  this  drug,  we  are  only 
willing  to  believe  in  the  futility  of  small  doses,  and  the  uncertainty 
as  yet  of  the  curative  effect  of  the  heroic  ones — notwithstanding  the 
notable  absence  of  any  untoward  effect  from  same. 

We  believe  that  frequent  bathing  and  careful  attention  to  diet 
should  receive  first  consideration  in  all  cases ;  and,  as  a  routine,  are 
accustomed  to  interdicting  all  articles  of  food  derived  from  maize. 
It  is  interesting  to  note  that  in  one  case  (negro  male)  after  apparent 


233 

recovery  an  exacerbation  of  gastro-intestinal  symptoms  and  ulti- 
mately death  followed  upon  the  surreptitious  addition  of  corn  bread 
to  his  diet.  A  stricely  milk  dietary  is  still  considered  the  best  form 
of  food,  for  our  pellagrins ;  and  to  this  is  added  toasted  bread,  with 
custards,  hot  eggs,  and  gradually  additions  of  other  food  stuffs 
(excepting  corn  products)  as  the  symptoms  abate. 

Prognosis :  While  the  death  rate  in  pellagra  is  notably  large, 
as  has  been  pointed  out  by  almost  all  writers  upon  this  subject,  yet 
sight  should  not  be  lost  of  the  fact  that  the  vast  majority  of  these 
cases  have  come  from  our  asylums  and  alms  houses,  where  condi- 
tions are  most  unfavorable  and  body  resistance  has  been  previously 
lowered  by  intercurrent  disease  and  debility.  Consideration  of  the 
cases  which  are  seen  by  physicians  in  general  practice,  and  a  careful 
search  into  the  histories  of  those  cases  received  into  our  hospitals, 
brings  to  light  much  of  interest  in  the  length  of  time  (even  twenty 
years  or  more)  over  which  this  condition  may  endure,  with  frequent 
remissions  and  recovery  and  without  seriously  incapacitating  the 
affected  individual,  even  though  unrecognized  and  without  proper 
dietary  treatment.  It  is  to  be  hoped  that  in  the  future  such  danger 
and  oversight  may  be  avoided,  and,  by  early  recognition  and  treat- 
ment, reduced  to  a  minimum. 

Of  the  five  cases  embodied  in  a  former  report  from  this  hospital, 
there  was  a  complete  subsidence  of  symptoms  in  one  case  (white 
man)  which  has  continued  to  present  time;  and  has  been  interrupted 
only  once  for  a  short  period  when  a  return  to  general  diet,  including 
daily  ration  of  corn  bread,  was  accompanied  by  slight  erythema  and 
slight  gastro-intestinal  symptoms. 

Of  the  thirteen  more  recent  cases,  eleven  of  which  were  among 
women,  there  has  been  complete  subsidence  of  symptoms  in  two, 
one  of  which  has  returned  home  and  two  more  still  under  treatment 
show  great  improvement  at  the  present  time,  with  prospects  reason- 
ably good  for  recovery.  All  the  cases  that  have  succumbed  have 
given  undisputed  evidence  of  serious  complicating  conditions,  such 
as  senile  debility,  tuberculosis  and  syphilis;  and  this  applies  with 
equal  force  to  the  new  cases  seen  among  the  men,  both  of  whom 
have  died. 

An  analysis  of  these  figures  gives  a  ratio  of  recovery  of  about 
one  in  every  four  or  five  cases — which  is  not  excessive  when  con- 
sideration is  given  to  the  complications  and  general  character  of  the 
patients  received.  The  one  case  (woman)  which  made  the  most 
rapid  and  satisfactory  recovery  (so  that  she  returned  home)  was  a 


234 

young  patient  from  the  middle  walks  of  life,  untainted  by  acquired 
or  inherited  disease. 

We  would  feel  it  incumbent  upon  the  medical  fraternity  to  seek 
to  allay,  as  far  as  possible,  that  unnecessary  and  widespread  alarm 
which  has  developed  so  rapidly  in  the  past  year  among  the  people 
of  the  South,  irrespective  of  class  or  condition,  regarding  this 
disease.  While  its  dangers  and  consequences  are  not  to  be  lightly 
considered  or  underestimated,  yet  the  prosperity  and  peace  of  mind 
of  our  entire  people  demand  that  we  should  look  at  the  matter  from 
a  more  subdued  and  conservative  viewpoint.  We  cannot  believe 
that  pellagra  is  destined  to  overrun  our  beloved  Southland,  as  it  has 
encompassed  the  portions  of  Southern  Europe  for  the  past  century 
or  more;  and  the  very  fact  of  its  early  recognition  among  us  pre- 
sages a  vigorous  warfare  against  its  encroachments,  and,  with  the 
aid  of  a  conservative  public  press  and  an  enlightened  and  scientific 
medical  body,  profiting  by  the  vast  experience  and  brilliant 
researches  of  our  European  confreres,  may  quickly  accomplish  the 
steps  necessary  for  its  complete  effacement  and  extermination.  To 
this  end  it  would  seem  to  the  essayists  that  Governmental  aid  and 
intervention  should  be  sought,  and  the  doctors,  as  guardians  of  the 
public  health,  while  allaying  the  fears  of  the  populace  and  teaching 
personal  hygiene  at  home,  should,  as  a  great  fraternity  of  no  mean 
political  importance,  urge  upon  our  representatives  in  Congress  the 
great  necessity  of  introducing  and  supporting  such  measures  as  will 
insure  a  fuller  execution  of  our  pure  food  and  drug  law  and  secure 
the  inclusion  of  our  corn  products  among  those  food  stuffs  receiving 
careful  Governmental  inspection  and  supervision. 


235 


CLINICAL   OBSERVATION   OF   FOUR   CASES   OF   PEL- 
LAGRA. 

REA  PARKERj  M.  D.^  PH.  B. 
First  Assistant  Physician  Eastern  State  Hospital 

WILLIAMSBUBGj    VA. 

Since  1735  pellagra  has  bafifled  the  skill  of  many  of  the  most 
eminent  scientists  of  the  world.  First  occurring  in  Spain,  then  in 
Italy,  where  it  followed  shortly  upon  the  introduction  of  maize  into 
that  country,  and  thence  from  first  one  country  to  another  it  has 
slowly  but  persistently  spread  its  wings  of  terror  until  its  shadow 
threatens  practically  every  nation  of  the  world.  The  combined 
efforts  of  the  best  thinkers  of  nearly  every  nation  have  accomplished 
but  little,  and  the  malady  is  now  in  practically  the  same  chaotic 
state  that  surrounded  it  a  hundred  years  ago.  With  the  exception 
of  the  occurrence  of  a  sporadic  case  in  1902,  and  one  or  two  others 
of  uncertain  diagnosis,  America  was  singularly  free  from  the  disease 
until  1906,  when  we  suddenly  found  ourselves  the  victim  of  this 
dreadful  malady  which  has  proven  a  veritable  scourge  to  portions  of 
Europe  and  other  countries. 

It  is  earnestly  hoped  that  we,  ourselves,  may  be  able  to  do  some- 
thing to  check  the  progress  of  this  disease  or  to  stimulate  others  to 
a  speedy  solution  of  the  problem. 

In  presenting  a  clinical  report  of  a  few  of  the  cases  of  pellagra 
that  have  come  under  my  personal  observation,  it  is  not  with  the 
idea  of  contributing  anything  new  on  the  subject,  but  rather  to 
give  the  profession  at  large  a  general  idea  of  the  disease  as  it  exists 
in  Virginia.  The  following  report  is  fairly  representative  of  the 
varied  clinical  manifestations  of  the  malady  as  it  is  seen  in  that 
State. 

In  September,  1908,  pellagra  first  appeared  in  Virginia  in  the  Cen- 
tral State  Hospital  on  the  wards  of  the  writer. 

Through  the  courtesy  of  Dr.  Drewry,  Superintendent  of  the  Cen- 
tral State  Hospital,  that  case  is  given  below  in  part  as  reported  by 
him  and  as  it  appeared  in  a  recent  edition  of  the  Virginia  Medical 
Semi-monthly : 

Augustus  J.  (6733) — Admitted  first  time  Sept.  7th,  1908,  sent 
to  his  home  Jan.  13th,  1909,  much  improved,  and  returned  to  the 
hospital  a  short  time  ago,  physical  and  mental  symptoms  herein 
described  having  returned  in  an  intensified  form. 


236 

He  was  born  and  raised  in  Southside,  Virginia ;  age,  55 ;  color, 
black ;  farm  laborer ;  no  education ;  habits  as  to  alcohol  and  other 
dissipations  good  (  ?)  ;  general  health  fair,  until  about  two  or  three 
years  ago,  when,  according  to  best  information  obtainable,  he  began 
to  have  occasional  diarrhoea,  feel  weak  and  good-for-nothing  and 
noticed  some  ''skin  trouble"  on  his  hands.  These  symptoms  were 
worse  in  spring  and  summer,  better  during  the  cold  months,  when 
they  almost  disappeared.    Have  been  unable  to  get  family  history. 

Patient  said — before  he  became  demented — that  he  always  had 
plenty  to  eat,  lived  in  a  fairly  comfortable  house,  and  worked  steadily 
on  the  farm,  that  he  got  his  meal  from  the  neighborhood  store,  and 
from  corn  he  raised  and  had  ground  at  the  country  water  mills. 

From  information  given  in  the  commitment  papers,  the  patient 
was  "sick"  in  the  spring  of  1908,  anri  in  the  follo\/ing  September 
was  much  weaker,  and  mental  symptoms  had  progressed ;  at  times 
he  was  excited,  at  other  times  depressed,  and  had  hallucinations  of 
fear,  thinking  some  one  was  trying  to  shoot  him. 

From  examinations  on  re-admission  and  frequently  since,  his 
clinical  history  is  here  given.  (We  made  a  tentative  diagnosis  of 
pellagra  last  fall  and  kept  the  patient  under  careful  observation.  Dr. 
Rea  Parker,  then  on  our  staff,  first  observed  the  symptoms,  and 
suggested  the  diagnosis  and  so  entered  on  the  records.) 

General  Physical. — Pulse  80-100;  respiration  12-20;  temperature 
963-5  to  99  F. ;  arteries  atheromatous;  blood  pressure  133  m.  m. ; 
heart  irregular ;  marked  accentuated  aortic  second  sound ;  lungs 
normal,  except  slight  bronchial  breathing  over  upper  left  infrac- 
lavicula  region;  general  prolonged  expiration;  liver  small;  muscles 
thin  and  inelastic,  producing  apparent  rigidity  or  stiffness  of  joints; 
progressive  emaciation ;  weakness  and  loss  of  weight ;  general  phy- 
sical debility;  anemia;  lipoma,  2  1-2  by  3  inches,  at  right  inferior  lat- 
eral costal  margin;  has  had  gonorrhoea;  brown  discoloration  of 
bulbar  conjunctiva;  and  arcus  senilis.  There  was  observed  in  this 
and  other  cases  a  peculiar  odor. 

Gastro-Intestinal. — Obstinate  and  exhaustive  diarrhoea,  with  occa- 
sional remission  prolonged  in  fall  and  winter;  stools  thin,  light 
yellow  or  dark  brown;  appetite  varied,  usually  very  poor,  at  times 
excessive  thirst. 

Mouth. — Unpleasant  breath,  stomatitis,  salivation,  ulcerated  gums, 
tongue  flabby,  otherwise  usually  normal  in  appearance,  except  some- 
times furred,  a  few  small  black  spots  on  the  dorsum  near  the  end. 

Skin. — Extending   from   glabella   downward,  'involving  the  alse 


237 

nasi,  the  malar  region,  outer  canthi,  the  tipper  and  lower  lips,  mental 
prominence,  and  on  the  sides  of  the  neck  there  was  a  distinct  dark 
pigmentation.  The  surface  of  the  face  covered  was  somewhat 
irregularly  butterfly  shaped.  Over  the  lower  portion  of  the  forehead, 
the  entire  nose  and  partly  over  the  face  there  was  a  hyperthrophy  of 
the  sebasceous  glands,  these  being  plugged  with  a  sebasceous 
material  resembling  a  typical  case  of  pityiriasis  pilaris.  The  cuta- 
neous affection,  the  anomalies  of  pigmentation,  and  the  saborrhoea 
observed  in  this  and  other  cases  do  not  correspond  with  skin  condi- 
tions frequently  seen  in  cases  of  insane  adolescents.  There  was  a 
rather  "mummy"  appearance  of  the  parts  affected,  involving  the 
thumbs  and  fingers,  and  extending  from  the  nails  to  about  two  and 
one-half  inches  up  on  the  wrists,  and  all  the  way  around,  the  line 
of  demarkation  being  distinct  and  symmetrical — glove  shaped.  The 
skin  lesion  on  the  hands  and  wrists  may  be  described  as  varying 
from  a  dark  pigmentation  to  a  dry  desquamation  and  exfoliation, 
part  of  the  surface  being  cracked  or  parchment  like,  but  there  was  no 
induration.  The  skin  on  the  tops  of  the  hands  "cleared  up"  some- 
what, in  places,  leaving  a  fairly  smooth  surface.  The  feet  were 
involved  to  a  limited  extent — the  external  malleolli  and  superior  sur- 
face of  the  dorsum  showing  more  or  less  defined  spots,  of  a  dark 
discoloration  and  a  slight  scaly  dessication.  About  the  scrotum, 
groins  and  region  around  the  rectum  there  was  a  moist  pruitus. 
There  were  also  external  hemorrhoids. 

Nervous  and  Mental. — Motor  paresis  marked ;  .unsteady  gait ;  dif- 
ficulty and  awkwardness — as  if  afraid  to  trust  himself — in  walking, 
sitting  down  or  getting  up;  bent  forward  attitude;  when  walking 
legs  far  apart;  pain  in  back  and  legs,  particularly  over  mid-dorsal 
region,  and  on  pressure  over  abdomen ;  occasional  headache,  varying 
in  intensity  but  usually  dull  in  character.  There  was  slight  itching 
over  the  surface  covered  by  the  cutaneous  lesions ;  patella  reflexes 
were  slightly  exaggerated,  later  abolished ;  insomnia  at  night,  drow- 
siness in  day.  With  some  remission  the  mental  symptoms  were  pro- 
gressive and  marked,  consisting  of  general  apathy,  dullness,  indif- 
ference, depression,  retardation,  confusion,  defective  memory,  dis- 
turbance of  attention,  clouding  of  consciousness,  incoherence, 
mutism,  melancholia,  mental  deterioration,  etc.,  and  finally  pro- 
nounced dementia.  At  no  time  did  the  patient  laugh  or  smile.  He 
died  Friday  afternoon,  September  3.  Dr.  James  C.  Bardin,  our 
pathologist,  assisted  by  Dr.  A.  W.  Freeman,  of  the  State  Health 
Department,  and  Dr.  M.  S.  Brent,  of  our  staff,  made  a  complete 


238 

post-mortem  examination  within  four  hours  after  death.  The  brain 
and  spinal  cord  were  sent  to  Dr.  Simon  Flexner,  of  Rockefeller 
Institute,  New  York.     Dr.  Bardin's  findings  were  as  follows : 

Chronic  pericarditis ;  hypertrophy  of  left  ventricle ;  very  marked 
chronic  fibrous  myocarditis ;  cloudy  swelling  of  heart  muscles ; 
chronic  endocarditis.  Chronic  adhesive  pleurisy,  both  lungs ;  atelec- 
tasis of  lower  lobe,  left  lung;  old,  healed  calcareous  tuberculosis 
foci  both  lungs ;  chronic  passive  congestion  both  lungs ;  chronic 
passive  congestion  abdominal  viscera.  Cloudy  swelling  of  the  liver. 
Atrophy  of  the  stomach.  Acute  duodenitis.  Chronic  atrophic  enter- 
itis ;  acute  enteritis  with  erosions.  Chronic  and  subacute  colitis. 
Chronic  appendicitis.  Arterio-sclerotic  nephritis,  both  kidneys. 
Arterio-sclerosis  and  atheroma  of  all  the  arteries,  extraordinarily 
marked  in  the  anterior  coronary. 

Case  i   (History  obtained  from  son  and  commitment  papers.) 

Family  History — Negative. 

Personal  History. — J.  K. ;  white,  male ;  Virginian ;  age  55 ; 
farmer;  education  fair;  married,  with  several  children,  all  of  whom 
a're  healthy.  Patient  has  lived  in  the  country  all  of  his  life;  early 
habits  regular;  ate  largely  of  corn.  In  the  spring  of  1902  his  health 
began  to  fail ;  showed  indisposition  to  work ;  suffered  with  head- 
ache and  vague  pains  throughout  the  body;  intermittent  diarrhoea; 
slight  reddening  of  back  of  hands,  forehead  and  neck;  insomnia 
developed,  followed  by  train  of  mental  symptoms — refusing  to  see 
his  best  friends,  claimed  he  was  lost  and  failing  to  recognize  family ; 
committed  to  S.  W.  S.  H.,  Va.,  in  1903 ;  diagnosis :  melancholia ; 
discharged  in  a  few  months  as  recovered ;  each  succeeding  spring 
brought  a  return  of  the  symptoms,  the  physical  predomination — 
diarrhcea  and  skin  lesions  with  increased  severity;  moved  to  Prince 
George  County,  Eastern  Virginia,  in  1906;  drank  heavily  a  part  of 
1907.  With  the  exception  of  a  slight  mental  depression  the  symp- 
toms cleared  up  during  the  winter.  In  the  early  spring  of  1909  the 
trouble  reappeared  in  a  greatly  exaggerated  form.  Admitted  to  the 
E.  S.  H.,  Va.,  July  26th,  1909.  Upon  admission  examination  showed 
the  following: 

Nervous  and  Mental  Symptoms. — Speech  slow  but  slurring; 
unsteady  gait ;  Romberg  symptom ;  Argyll-Robertson  pupil ;  patella 
reflexes  diminished;  patient  said  he  slept  but  little.  There  was 
marked  depression  with  some  irritability.  He  was  apprehensive, 
through  had  but  little  insight  into  his  condition  and  showed  defective 
judgment. 


239 

Physical  Symptoms. — Somewhat  emaciated;  musculature  poor 
tone ;  epitrochlear  glands  enlarged ;  complained  of  pain  in  rectum  and 
at  times  in  breast,  bones  and  joints. 

Circulatory  System. — Slight  mitral  lesion,  pulse  95,  small  and 
irregular,  arteries  somewhat  atheromatous. 

Respiratory  System. — Negative. 

Alimentory  System. — Tongue  coated;  breath  offensive;  appetite 
poor;  stomach,  liver  and  spleen  showed  nothing  of  interest;  slight 
serous  diarrhoea. 

Skin. — The  skin  over  forehead  was  very  red  and  rough.  The  back 
of  the  neck  and  supra-scapular  regions  were  red  and  indurated  and 
to  a  certain  extent  extending  from  the  junction  of  the  first  and 
second  joint  of  the  fingers  to  a  point  about  one  inch  above  the  styloid 
process  of  the  ulnar,  showed  dry  furred  scales,  beneath  which  the 
skin  was  dark  red.  The  dorsal  surface  of  the  forearms  presented 
the  appearance  that  the  skin  would  show  about  two  days  after  a 
superficial  scald. 

Course  of  the  Disease. — For  the  first  week  his  condition  remained 
about  the  same  as  upon  admission.  The  diarrhoea  became  worse  and 
not  amenable  to  treatment ;  salivation  also  began  about  this  time ;  the 
tongue  became  red  and  slightly  swollen.  These  conditions  gradually 
grew  worse  and  at  the  beginning  of  the  third  week  after  admission 
nausea  and  vomiting  set  in,  at  the  same  time  the  reddened  tongue 
became  denuded.  The  skin  condition  on  the  back  of  the  neck  and 
supra-scapular  regions  gradually  cleared  up  during  this  and  the  pre- 
ceding week  and  the  skin  over  the  chest  and  elbow  began  to  show 
involvement.  The  perineal  region  became  red  and  oedematous ;  con- 
ditions remained  practically  the  same  as  third  week  with  added  loss 
of  appetite,  the  patient  refusing  food  but  craved  acids,  which  he 
refused  when  offered  him.  At  the  beginning  of  the  5th  week  the 
involvement  of  the  skin  over  the  breast,  which  began  about  the 
middle  of  the  4th  week  became  more  prominent  and  by  the  end  of 
this  week  it  involved  the  supra-clavicular  regions  having  a  triangular 
shape,  the  base  of  the  triangle  being  formed  by  the  clavicle  with 
apex  extending  to  the  epigastric  notch.  While  this  was  the  area 
involved  it  did  not  show  a  well  defined  line  of  demarcation  until 
the  latter  part  of  the  week  and  the  beginning  of  the  6th  week.  The 
Condition  on  the  forearm  during  this  time  had  become  dry  and 
scaly.  Physical  decline  and  general  weakness  was  more  rapid  dur- 
ing the  last  few  days  of  this  week.  At  the  beginning  of  the  6th 
week  the  skin  condition  over  chest  showed  a  line  of  well  marked 


240 

demarcation,  the  skin  being  thickened,  pigmented  and  somewhat 
roughened.  The  diarrhoea  condition  remained  unchanged.  He 
became  so  weak  that  he  was  unable  to  raise  himself  in  bed.  Tongue 
remained  red  and  denuded;  about  this  time  the  patient  began  to 
show  marked  dementia,  which  became  more  continuously  pro- 
nounced. The  perineal  condition  improved,  while  the  other  skin 
conditions  remained  as  last  stated.  At  this  time  he  was  taking  nour- 
ishment somewhat  better.  On  the  evening  of  the  38th  day  he  had  a 
mild  convulsion,  pupils  becoming  irregular,  dilating  and  contracting 
alternately  without  any  external  stimidi,  one  pupil  reacting  inde- 
pendently of  the  other;  during  that  afternoon  the  patient  was  at 
times  excited;  the  next  day  he  began  showing  hallucinations,  both 
auditory  and  visual,  also  expressing  some  few  delusions.  Patient 
continued  in  a  delirious  condition  through  this  and  the  next  day, 
dying  at  3  :45  a.  m.  the  following  morning.  Repeated  urinary  exam- 
inations showed  acid  reaction;  sp.  gravity  varying  from  1.017  to 
1.020,  indican,  few  epithelial  cells  and  an  occasional  hyaline  cast. 
Examination  of  feces  showed  no  evidence  of  hookworm.  Repeated 
examination  of  the  blood  showed  the  following : 

Polynuclear  neutrophiles  85;  lymphocytes  11.5;  large  mononu- 
clear 3.5;  transitional  3.5;  polynuclear  eosinophiles  o;  mast  cells  .3. 

Case  i  (Dr.  Mary  Roche's  case)  History  obtained  from  commit- 
ment papers. 

Mrs.  M.  (1157),  admitted  to  Eastern  State  Hospital  September 
21,  1909;  v/hite;  female;  age  33;  married,  with  three  children, 
youngest  twenty  months  old.  There  was  no  history  of  insanity  in 
the  parents  or  near  relatives  of  the  patient;  cause  of  insanity  not 
given.  Mental  symptoms  were  first  noticed  in  June,  1905,  four 
years  previous  to  admission,  with  marked  depression  and  delusions 
fearing  some  one  was  going  to  kill  her. 

Upon  admission  the  patient  was  very  weak  and  emaciated  and 
suffering  with  diarrhoea.     Temperature  subnormal;  pulse  120-130,. 
low  tension.    There  was  complete  anorexia,  nausea  and  vomiting. 

Physical  Examination. — Patient  a  small,  emaciated  woman, 
expression  anxious,  eyes  sunken,:  pupils  widely  dilated,  reacted 
sluggishly  to  light.  Across  the  forehead  beginning  about  three  cm. 
below  the  hair  line  is  an  irregularly  outlined  pigmented  area  extend- 
ing down  oh  right  cheek.  On  dorsal  surface  of  hands,  particularly 
over  the  articulations,  wrist  and  feet  the  skin  was  slightly  thickened 
and  covered  with  dry,  harsh,  brownish  scales.  The  little  finger  of 
one  hand  showed  some  contractions  of  flexors.     There  was  slight 


241 

thickening  of  radial  arteries;  muscles  atrophied  and  slightly  rigid. 
Patient  lying  on  her  side  with  knees  drawn  up;  pulse  weak  and 
small,  100-120;  heart,  second  sound  clear,  first  sound  soft  and  blow- 
ing ;  lungs  negative ;  tongue  red  and  fissured ;  flow  of  saliva  almost 
constant ;  teeth  poor ;  breath  fetid  ;  appetite  poor ;  liver  and  spleen  not 
palpable;  abdomen  retracted.  Patella  reflexes  irregular,  increased 
on  right  side,  diminished  or  absent  on  left. 

Vaginal  examination  showed  vulva  very  red  and  inflamed,  vaginal 
mucosa  very  red ;  there  was  a  deep  lateral  tear  of  cervix ;  uterus 
retroflexd  and  slightly  enlarged. 

Mental. — Patient  was  markedly  depressed,  almost  constant  mutism, 
occasionally  answered  a  question  intelligently,  muttering  sometimes. 
After  admission  the  patient  grew  steadily  weaker;  temperature 
ranging  from  97-100  F.  Diarrhoea  with  very  offensive  odor  was  at 
first  marked,  but  eventually  controlled  by  an  acid  diarrhoea  mixture 
containing  morphine.  Intestinal  antiseptics  were  given,  but  with 
no  material  effect  upon  the  odor  of  the  stools.  At  first  nausea, 
vomiting  and  salivation  were  marked,  nothing  being  retained  for  the 
first  few  days  but  albumen,  later  peptonized  milk  and  selected  diet 
was  given.  Hiccough  was  very  troublesome  at  times.  When  first 
admitted  there  was  a  purulent  vaginal  discharge  which  improved 
later  under  treatment  by  douches.  No  hookworm  was  found  in  this 
case. 

From  such  history  as  could  be  obtained,  together  with  the  clinical 
manifestations  of  the  case,  I  made  a  tentative  diagnosis  of  pellagra — 
my  diagnosis  being  later  confirmed  by  one  of  my  associates  at  the 
hospital  who  had  seen  and  studied  a  number  of  cases.  The  patient 
died  October  10,  1909.     No  post-mortem  was  obtained. 

Case  III — Geo.  M.  (508),  admitted  from  Accomac  County  April 
loth,  1887;  white;  age  46;  single;  occupation,  farmer;  habits  not 
given ;  no  history  of  heredity ;  suicidal  tendency.  Duration  of  insan- 
ity previous  to  admission  four  months ;  cause  unknown. 

Upon  admission  mental  symptoms  indicated  dementia  prsecox. 
There  was  nothing  of  special  interest  in  his  history  since  admission, 
except  a  chronic  ulcer  over  the  left  mastoid  region,  until  last  spring, 
at  which  time  dementia  became  more  marked.  A  search  for  hook- 
worm was  negative.  During  June  and  July  the  irregular  diarrhoea 
became  worse,  appetite  fickle  and  the  skin  on  back  of  hands  red  and 
indurated.  Over  the  forehead  and  portions  of  the  face  the  skin  was 
covered  with  dirty  brownish  looking  scales  about  1-8  inch  in  diam- 
eter. The  removal  of  these  scales  with  soap  and  antiseptic  solutions 
16— P.  c. 


242 

left  that  portion  of  the  skin  covered  with  dark  liver-colored  spots 
over  which  new  scales  soon  formed.  The  sebaceous  glands  were 
hypertrophied  and  occasionally  covered  with  a  fine  mealy  looking 
substance.  The  reflexes  were  diminished ;  pupils  sluggish ;  gums  red 
and  spongy  while  the  flow  of  saliva  became  increased.  This  man 
rarely  ever  spoke  or  took  any  interest  in  anything  around  him.  About 
the  first  of  October  he  became  much  weaker,  refusing  both  food  and 
medicine.  At  this  time  a  systolic  murmur  could  be  heard  over  the 
mitral  area. 

On  October  the  5th  the  abdomen  became  distended  and  three  days 
later  there  was  positive  evidence  of  fluid  in  the  abdominal  cavity. 
On  the  morning  of  the  i6th  he  was  in  a  state  of  profound  shock.  I 
tapped  him  that  afternoon,  withdrawing  a  portion  of  the  fluid,  about 
95  ounces,  which  showed  nothing  unusual  under  the  microscope.  He 
continued  to  grow  weaker,  dying  at  1 1 145  p.  m.  Post-mortem  not 
obtained. 

In  conclusion,  I  wish  to  enter  a  plea  in  behalf  of  those  already 
affected  and  of  those  who  are  liable  at  any  time  to  become  the  victims 
of  this  disease,  that  this  conference,  representing  as  it  does  every, 
or  nearly  every  State  in  the  Union,  and  many  countries  instruct 
each  State  committee  to  request  the  Legislature  of  their  respective 
State  to  pass  and  rigidly  enforce  such  laws  relative  to  the  method 
of  cultivating,  harvesting,  maturing,  preserving  and  milling  Indian 
corn  as  seem  practical  and  necessary. 

I  do  not,  gentlemen,  wish  to  appear  an  alarmist,  but  why  wait  to 
appeal  to  the  public  to  do  what  it  can  to  protect  us  from  this  invading 
enemy  until  thousands  and  millions  of  useful  lives  are  sacrificed  and 
the  influence  of  heredity  defies  the  nation  for  hundreds  of  years? 


243 


PELLAGRA  AT  EAST  MISSISSIPPI  INSANE  HOSPITAL 

J.    M.  BUCHANAN^   M.  D, 
Superintendent  State  Hospital 

MEHIDIANj   MISS. 

At  the  request  of  Dr.  Babcock  I  am  presenting  short  histories  of 
the  cases  of  pellagra  at  the  East  Mississippi  Insane  Hospital,  but 
they  do  not  present  any  points  of  special  interest,  and  I  do  not  feel 
that  I  can  add  anything  new  to  the  question  under  consideration. 

These  cases  do  establish  the  fact  that  pellagra  existed  in  our  State 
for  several  years,  unrecognized,  for  they  give  histories  of  two  to  ten 
years'  duration.  However,  I  do  not  think  pellagra  cases  occurred  in 
bunches  prior  to  1906,  and  the  first  known  case  in  Mississippi  was 
observed  at  the  insane  hospital  in  November,  1907,  although  it  was 
not  recognized  as  pellagra  until  after  the  appearance  of  Dr.  Bab- 
cock's  report,  which  was  several  months  after  the  death  of  the 
patient. 

I  am  sure  this  was  the  first  case  in  the  hospital,  for  with  the  small 
number  of  patients  (500)  I  have  been  able  to  be  familiar  with  every 
case  for  the  last  twenty  years,  and  a  retrospection  fails  to  show  a 
suspicious  case. 

In  April,  1908,  Dr.  W.  R.  Card  made  a  report  of  two  cases  before 
the  Mississippi  State  Medical  Association,  but  that  report  did  not 
command  a  passing  notice.  Since  then  seven  other  cases  have  been 
received.    No  case  has  developed  in  the  hospital. 

I  have  no  data  as  to  the  number  of  cases  in  Mississippi,  but  as 
many  reports  have  been  made  from  various  sections,  I  feel  safe  in 
saying  the  number  has  passed  the  100  mark. 

I  believe  in  the  zeist  theory,  and  tried  to  lay  the  cause  to  imported 
Western  meal,  but  three  of  my  patients  came  from  interior  counties, 
and  their  people  state  that  all  the  meal  used  was  from  home-grown 
corn,  ground  at  nearby  mills. 

I  have  known  pellagrins  to  be  made  worse  by  eating  good  corn 
bread,  and  it  seems  that  there  may  be  something  in  the  bread  itself 
that  causes  the  trouble,  and  it  may  not  be  altogether  due  to  the  sup- 
posed toxine. 

Careful  inquiry  fails  to  find  a  local  cause.  All  were  country  peo- 
ple— fairly  well-to-do,  living  in  open  houses,  and  using  good  spring 
or  well  water.  While  they  did  not  come  from  any  particular  sec- 
tion, all  came  from  the  hilly  and  sandy  regions,  and  none  were  from 
the  delta  or  prairies. 


244 

In  some  cases  skin  lesions  were  the  first  symptoms  noted.  In 
others,  general  bad  health  and  diarrhoea  were  first  noticed — the  skin 
lesions  appearing  later.  In  one  case  there  was  a  recrudescence  of 
the  symptoms  for  ten  years,  with  mental  symptoms  appearing  last, 
but  this  may  have  been  a  coincidence,  as  she  has  a  brother  who  is 
insane. 

Our  treatment  was  practically  the  same  for  all,  and  consisted  of 
tonics  and  special  diet.  Atoxyl  was  given  by  deep  injections,  begin- 
ning with  one  grain,  and  increasing  up  to  four  or  six  grains  per 
day.  For  the  bowel  trouble  beta  napthol  in  combination  with  astrin- 
gents seemed  to  give  best  results.  Z.  O.  ointment  was  used  as  a 
dressing  for  the  skin  lesions. 

Some  showed  marked  nervous  troubles,  possibly  spinal,  but  as  no 
post-mortem  could  be  had,  we  have  nothing  definite  as  to  out  lesions. 
Others  presented  only  mental  symptoms.  The  mental  manifesta- 
tions were  of  the  manic  depressive  type,  and  were  quite  variable. 

In  three  cases  there  was  known  hereditary  taint. 

Of  the  nine,  one  made  a  good  recovery  both  mentally  and  physi- 
cally. Two  recovered  from  somatic  troubles,  with  little  improvement 
of  mind.  Three  died,  and  three  are  still  under  observation  with  no 
improvement. 

Case  No.  i. — J.  E.  B.,  No.  2292.  Male;  age  44;  farmer;  was 
admitted  from  Clark  County,  Miss.,  Nov.  7th,  1907. 

There  was  a  marked  erythematous  eruption  on  his  face,  back  of 
neck,  hands  and  forearms — having  the  appearance  of  being  sun- 
burned. Patient  was  suffering  from  a  persistent  diarrhoea — was  very 
anemic — quite  thin  and  weak.  Slept  but  little  and  had  a  poor  appe- 
tite.    No  temperature. 

The  nervous  manifestations  were  very  marked — being  quite  rest- 
less and  excitable,  but  did  not  complain  of  any  pains.  Reflexes 
exaggerated. 

His  mental  symptoms  were  those  of  acute  melancholia — said  to 
be  of  four  weeks'  duration.  He  was  immediately  put  to  bed  and 
given  treatment  for  diarrhoea,  and  also  put  on  tonic  treatment.  The 
skin  lesions  were  treated  with  Z.  O.  ointment.  The  patient  improved 
somewhat  mentally,  and  the  eruption  on  face  and  hands  improved 
under  treatment.     Diarrhoea  persisted. 

Patient  died  from  exhaustion  in  three  weeks  after  admission. 
Case  was  not  diagnosed  as  pellagra  until  after  death — consequently 
no  history  of  the  early  stages  were  obtained. 


245 

Case  No.  2. — Mrs.  C.  J.,  No.  231 1;  age,  22;  married  three 
months ;  admitted  from  Wayne  County,  March  3rd,  1908. 

This  patient  was  seen  in  consultation  about  last  of  February  on 
account  of  mental  troubles.  A  diagnosis  of  pellagra  was  made,  and 
on  account  of  mental  disturbance,  it  was  advised  that  she  be  sent  to 
the  insane  hospital. 

First  symptoms  appeared  on  face  and  hands  in  small  splotches 
three  months  prior  to  admission.  The  eruption  soon  spread  over 
face,  :^eck  and  breast,  also  affected  the  hands,  elbows  and  shoulders. 
The  skin  lesions  had  been  treated  with  crysophanic  acid  by  family 
physician. 

There  was  no  diarrhoea  and  bowels  were  irregular.  Appetite  poor 
— refusing  food — and  was  wasting  rapidly. 

Reflexes  lively.  Complained  of  pains  in  feet  and  legs  on  pressure 
— not  able  to  w^alk — feet  w^ould  draw  and  could  not  stand. 

Tongue  red — mouth  sore  with  excessive  salivation.  Pupils 
dilated — slept  but  little. 

Six  months  prior  to  admission  had  been  frightened  by  some  one 
trying  to  enter  her  room.  Since  that  time  had  been  nervous  and 
hysterical.  When  first  seen  she  had  lucid  intervals,  but  had  charac- 
teristic hysterical  mania,  with  periods  of  extreme  excitement — crying 
and  noisy. 

On  loth  high  temperature  developed,  and  she  gradually  grew 
worse  and  died  from  heart  failure  on  next  day. 

Was  fond  of  corn  batter  cakes,  but  did  not  eat  more  than  other 
members  of  family. 

Case  No.  3. — Wm.  C,  No.  1984;  admitted  from  Lamar  County 
May  1 2th,  1909. 

This  man  was  a  former  patient  of  this  hospital,  having  been  treated 
for  acute  mania  from  March  3rd  to  June  6th,  1905,  at  which  time 
he  escaped.  Mental  condition  was  greatly  improved.  During  the 
stay  here,  there  was  no  eruption  on  skin  nor  other  somatic  dis- 
order. 

He  remained  at  home  and  farmed  until  May  12th,  1909,  when  he 
was  returned  to  the  hospital. 

When  received  second  time  there  was  extreme  emaciation,  offen- 
sive diarrhoea — erythematous  exudative  lesions  on  back  of  hands 
and  forearms,  legs  and  shins.  The  face  was  rough  and  scaly,  and 
there  was  a  V-shaped  mark  on  the  neck  and  breast  where  the  shirt 
had  been  opened.  On  account  of  extreme  weakness,  patient  was 
unable  to  walk. 


246 

There  were  no  nervous  manifestations.  Reflexes  normal.  The 
mental  symptoms  were  melancholia,  stupor  and  apathy. 

Was  treated  with  deep  injections  of  atoxyl  and  tonics.  Beta 
naphthol  in  combination  seemed  to  control  the  diarrhoea.  Eruption 
yielded  to  Z.  O.  ointment. 

Patient  still  under  observation — pellagra  entirely  cured.  Has 
gained  in  weight  and  is  robust  looking.     Mind  much  improved. 

Case  No.  4. — Mrs.  B.  J.,  No.  2470;  age  37;  widow;  admitted 
February  23rd,  1909,  from  Chickasaw  County. 

Family  history  not  good.  Several  members  reported  to  be  very 
nervous.  Patient  was  extremely  thin.  Diarrhoea — red  tongue — 
offensive  breath  with  no  salivation.  Marked  mental  depression,  with 
occasional  outbursts  of  excitement;  destructive  and  untidy. 

Duration  of  mental  disturbance,  one  month.  This  appears  to  have 
been  a  case  of  "pellagra  sine  pellagra,"  as  she  presented  all  charac- 
teristic symptoms  of  pellagra,  except  the  eruption. 

About  six  months  after  the  admission  characteristic  pellagrous 
erythema  appeared  on  hands  and  arms  confirming  the  diagnosis. 

Unable  to  obtain  any  definite  history  as  to  mode  of  living,  but  is 
from  well-to-do  people.  Patient  still  under  observation,  and  has 
been  given  the  usual  treatment  for  pellagra,  without  any  apparent 
benefit. 

Case  No.  5.— Mrs.  A.  J.,  No.  251 1;  admitted  June  2nd,  1909, 
from  Jasper  County,  Miss. ;  married ;  farmer's  wife.  Family  history 
bad — grandmother  and  one  first  cousin  insane.  Duration  of  attack, 
three  weeks;  acute  melancholia — extreme  emaciation. 

History  by  family  physician  very  unsatisfactory.  Patient's  condi- 
tion too  grave  to  make  an  examination.  Characteristic  eruptions  of 
pellagra  on  her  hands — with  bowel  symptoms.  Patient's  condition 
grew  rapidly  worse,  and  died  on  the  8th. 

Case  No.  6. — Mrs.  Sallie  R.,  No.  2531 ;  admitted  June  2nd,  1909. 
from  Itawamba  County,  Miss. 

Age  43 ;  widow  ;  four  children ;  former  family  history  bad.  Has 
one  brother  in  hospital.  Has  been  having  eczema  for  ten  years 
during  the  spring  and  summer  while  working  in  the  field.  Always 
got  better  in  winter. 

Health  began  to  fail  in  early  spring  of  1909,  but  continued  to  work 
in  field  until  May,  when  the  eruption  returned.  Diarrhoea  and 
mental  symptoms  developed  at  this  time.    Reported  to  have  had  a 


247 

spell  of  some  kind  of  paralysis — could  not  walk  or  talk,  and  lasted 
about  a  week,  and  was  then  sent  to  hospital. 

On  admission  her  physical  condition  was  fair,  appetite  good — 
stout  and  apparently  well  nourished.  Had  some  diarrhoea,  which 
had  been  worse.  Tongue  red — patches  in  mouth — increased  flow 
of  saliva — erythematus  exudative  lesions  on  back  of  hands  and 
both  breasts,  scattering  on  abdomen  and  thighs — no  pains.  Reflexes 
normal — mental  state  that  of  melancholia — talks  but  little — has  had 
two  attacks  of  lethargy,  with  mutism,  etc. 

Patient  still  under  observation  with  but  little  improvement,  except- 
ing skin  lesions,  which  are  about  well. 

Ate  corn  bread,  meal  made  from  home-grown  corn,  ground  at 
nearby  mill. 

Case  No.  7. — ^Mrs.  A.  M.,  No.  2534.  Admitted  from  Lowndes 
County,  July  30th,  1909. 

Physical  condition  good — nothing  abnormal — characteristic  pel- 
lagrous eruption  on  face,  hands  and  breasts,  which  was  almost  well 
on  admission.  Family  history  bad — uncle  and  aunt  insane — ^patient 
has  acute  mania  of  four  months'  duration. 

Was  committed  by  jury  on  account  of  mental  disturbance,  and  no 
history  accompanied  patient.  Patient  still  under  observation.  Erup- 
tion entirely  healed — no  improvement  in  mind. 

Case  No.  8. — Mrs.  Sallie  H.,  No.  2537.  Admitted  from  Union 
County,  Miss.,  August  3rd,  1909 ;  age,  53 ;  married. 

No  history  accompanying  patient.  She  says  there  has  been  an. 
eruption  on  hands  for  three  years  during  the  spring — diarrhoea  was- 
very  bad  at  times. 

Was  convalescent  on  admittance.  Hands  and  arms  presented  well- 
defined  discoloration  and  the  demarcation  between  affected  and 
healthy  skin  was  perfect  and  characteristic. 

Had  used  corn  bread  made  from  home-grown  corn. 

Mental  state,  excitement,  alternating  with  depression. 

Discharged  restored  October  19th,  1909. 

Case  No.  9. — Mrs.  Mollie  L.,  No.  2571.  Admitted  from  Clark 
County,  October  14th,  1909.  Age,  33;  married;  four  children; 
farmer's  wife ;  family  history  good ;  father  died  of  tuberculosis. 

Personal  history  states  that  in  spring  of  1907  she  had  severe 
diarrhoea  lasting  until  July.  In  April,  1908,  diarrhoea  returned  and 
there  was  a  skin  eruption.  These  symptoms  continued  until  July, 
when  she  got  better  again.     In  March,  1909,  practically  the  same 


248 

conditions  as  the  previous  year  developed,  but  did  not  get  better  in 
July.  On  September  23rd  she  developed  a  temperature  and  soon 
became  flighty.  This  was  thought  to  be  a  simple  delirium  from 
fever — and  severe  headaches.  After  this  she  began  to  talk  inco- 
herently with  only  occasional  lucid  periods — not  sleeping  much. 
When  first  admitted  there  was  extreme  emaciation  and  weakness. 
Characteristic  eruption  on  hands,  face  and  neck.  Profuse  salivation 
— tongue  red  and  mouth  sore.  Bowels  constipated.  No  pains  in 
head  or  legs.    Reflexes  exaggerated — pupils  dilated. 

Urine  showed  some  albumen  and  casts. 

Blood  examination — Color  index  by  Talquist  scale  60  per  cent. ; 
red  cells,  3842400.  Slight  Poykelocytosis,  white  cells,  12860.  Thirty 
per  cent,  of  which  were  large  Lymphocytes. 

Patient  has  failed  to  respond  to  any  treatment,  and  is  gradually 
becoming  weaker.  Mental  symptoms  more  pronounced,  and  death 
does  not  appear  to  be  far  away. 


249 


REPORT  OF  A  CASE  OF  "PELLAGRA  UNIVERSALIS." 

J.    RODDEY    MILLER,    M.   D, 

EOCK  HILL.    S.   C. 

Patient :  S.  F.  R.,  white,  male,  age  57  years.  Native  of  this  State, 
has  lived  all  his  life  in  the  Piedmont  region  of  South  Carolina.  His 
life  has  been  spent  upon  a  farm,  where  he  did  general  farm  work. 
Six  years  ago,  when  51  years  of  age,  moved  into  town  and  began 
work  as  a  carpenter. 

He  is  a  man  of  limited  means,  but  has  always  lived  well  or  had 
good  food  and  been  comfortably  clothed  and  sheltered.  Has  never 
been  intemperate  in  mode  of  living  or  in  drink. 

Family  History:  Father  and  mother  were  natives  of  this  State. 
Father  died,  aged  54,  of  apoplexy.  Mother  died  of  pneumonia,  aged 
67  years.  Has  four  brothers — ages  54,  59,  65  and  70  years.  Has 
three  sisters — ages  69,  71  and  73  years.  One  sister  died  at  12  years 
of  age  of  measles.    He  is  the  father  of  six  children.    All  healthy. 

Personal  History :  Patient  has  always  been  rather  thin  and  of 
spare  build.  Weighed  before  illness  125  pounds — 5  feet  8  inches  in 
height.  Had  typhoid  fever  when  25  years  of  age  and  pneumonia  at 
30.    Made  complete  recovery  from  both  illnesses. 

When  about  20  years  of  age  was  "salivated"  after  taking  calomel. 

Present  Illness :  During  summer  of  1906  patient  became  much 
debilitated,  weak — had  loss  of  appetite,  had  no  pain  except  occasional 
headache,  no  diarrhoea.  He  spent  two  weeks  at  a  mineral  springs, 
which  he  says  helped  him.  The  approach  of  cold  weather  gave  him 
strength,  so  that  he  was  able  to  continue  his  work  during  the  winter 
months  of  1906  and  1907.  In  June  of  1907  became  weak — no  appe- 
tite— about  the  same  as  the  previous  summer.  This  continued  until 
October. 

The  following  summer,  July,  1908,  again  became  debilitated ;  could 
take  only  limited  amount  of  exertion ;  had  loss  of  appetite ;  no  pain ; 
was  obliged  to  give  up  his  work. 

During  October,  1908,  diarrhoea  of  moderate  intensity  developed, 
which  continued  a  greater  portion  of  the  winter.  Patient  had  not 
consulted  a  physician  until  in  December,  1908,  when  he  began  to 
have  "indigestion  and  diarrhoea,"  as  he  expressed  his  condition  at 
the  time. 


250 

Patient  came  to  my  office  for  advice  April  3d,  1909.  Temperature 
normal,  pulse  76 — tongue  coated  slightly;  no  pain;  complains  of 
uncomfortable  feeling  about  stomach ;  has  "indigestion  and 
diarrhoea,"  as  he  says.  An  examination  fairly  complete  revealed 
nothing. 

At  the  time  of  second  visit  patient  no  better;  diarrhoea  more 
troublesome ;  has  from  three  to  six  movements  during  morning 
hours.  Movements  are  loose  and  watery;  very  little  pain.  April  15, 
feet  and  legs  swollen.  (Edema  is  in  feet  and  legs,  half  way  up  to 
knee  joint;  both  feet  and  both  legs  have  the  oedema. 

Frequent  examinations  of  heart,  lungs  and  kidneys  revealed  noth- 
ing. Urine  was  always  found  in  good  condition — no  albumen,  no 
sugar,  slightly  acid  in  reaction.  Some  days  the  quantity  of  urine  less 
than  others.  This  time  swelling  of  feet  continued  only  one  week. 
On  the  1 8th  of  April,  just  two  or  three  days  before  swelling  of  feet 
disappeared,  an  erythema  developed  upon  back  of  hands  and  over 
thumbs.  The  skin  appeared  as  if  slightly  burned,  swollen,  painful 
on  pressure.  On  second  or  third  days  afterwards  a  few  vesicles 
came  which  contained  small  quantity  of  yellowish  fluid.  This 
erythema  extends  only  to  the  wrist ;  same  on  both  hands.  This  con- 
dition of  hands  continued  only  about  ten  or  twelve  days,  when  they 
had  healed  and  dried ;  skin  became  rough,  cuticle  pealed  in  places.  In 
short  time  skin  on  hands  had  become  almost  natural ;  remained  little 
rough  in  places. 

During  the  period  when  patient  had  the  swelling  in  feet  and  the 
erythema  on  hands,  he  says  he  did  not  sleep  well ;  was  nervous. 
Knee  jerked  or  tendon  reflex  Sometimes  seemed  exaggerated,  at 
other  times  no  more  than  natural. 

In  the  month  of  May  patient  began  to  improve  or  get  stronger, 
better  appetite ;  slept  well ;  no  swelling  of  feet,  no  rash. 

This  condition  of  improvement  continued  for  eight  weeks — part 
of  May,  June  and  into  July.  Patient  began  to  do  light  work  and 
said  he  felt  as  well  as  he  had  in  years. 

July  25th  to  30th  patient  began  to  feel  unwell  again — had  headache 
every  day ;  appetite  failed ;  diarrhoea  returned. 

July  30th,  examination  of  heart,  lungs  and  kidneys  revealed  noth- 
ing abnormal. 

Tongue  red,  gums  swollen,  saliva  greatly  increased,  but  no  odor 
about  the  discharge.  In  a  few  days,  on  August  4,  mouth  gave  a 
great  deal  of  pain,  tongue  red,  papillse  prominent,  superficial  ulcera- 
tion on  inner  side  of  lips  and  under  tongue. 


251 

About  this  time  (second  week  in  August)  a  rash  began  upon 
back  of  hands.  This  is  the  second  time  the  erythema  appears.  The 
eruption  began  on  back  of  hands  and  forearm — here  the  skin  has 
dark,  reddish  appearance,  at  first  smooth,  on  second  or  third  day  is 
puffed,  with  few  scattered  vesicles  containing  yellowish  fluid,  in  a 
few  days  vesication  disappears,  leaving  a  dry,  scaly  surface  of  dark 
red  appearance.  The  eruption  first  appeared  upon  hands  and  fore- 
arm, but  by  the  end  of  first  week  had  appeared  upon  arms,  face, 
chest,  head  and  back.  From  loth  of  August  to  25th  of  August 
more  and  more  surface  of  the  body  developed  the  rash,  until  it 
covered  the  entire  body.  Patient's  mind  clear  at  all  times.  The 
only  mental  involvement  was  a  far-away  expression  and  general 
apathy,  so  that  patient  seemed  dull  or  listless.  Exposed  surface  of 
body  no  more  affected  than  unexposed.  There  were  a  few  spots,  or 
patches,  where  the  skin  was  not  so  red  and  the  vesicles  were  less 
in  number;  this  was  the  case  upon  the  under  surface  of  forearm, 
under  the  Axilla  and  upon  the  calf  of  the  legs.  The  vesicles  were 
not  numerous  in  any  one  place,  but  scattered,  nor  did  they  become 
very  prominent  or  large,  but  were  rather  small  vesicles  upon  a  broad 
base;  vesicle  would  dry  in  two  or  three  days  and  skin  become  scaly 
and  harsh. 

The  vesication  was  not  so  marked  a  condition  as  the  dark  reddish 
appearance  of  the  skin  of  the  entire  body,  first  smooth  but  in  a  few 
days  became  rough  and  dry. 

The  skin  on  arms,  hands  and  face  had  become  scaly,  rough  and 
thickened  by  the  time  the  eruption  appeared  upon  the  lower  limbs 
and  abdomen. 

At  no  time  has  patient  had  elevation  of  temperature  over  99 
degrees  F.  Several  times  during  the  eruption  and  ptyalism  temper- 
ature was  registered  at  99  degrees  F.  Pulse  generally  74  to  80  per 
minute. 

Some  weeks  pulse  ran  76  per  minute,  then  for  few  days  would  be 
80  per  minute.  From  the  appearance  of  the  erythema  the  second 
time  and  the  ptyalism,  the  patient  was  confined  to  bed  most  of  the 
.  time ;  preferred  to  lie  in  bed  because  the  feet  were  tender  and  pained 
when  pressed  to  the  floor.  First  September — Vesicles  have  all  dis- 
appeared. Scaly,  rough,  red  condition  of  skin  continues.  Patient 
gaining  strength  and  appetite  improving,  but  the  exfoliation  is 
marked. 

September  10 — Patient  gaining  in  strength,  good  appetite,  bowels 
act  only  once  a  day,  skin  dry,  scaly,  thickened,  dark  reddish,  covered 


252 

with  whitish  scales,  except  where  the  dry  scales  have  recently  been 
rubbed  away.  After  rubbing  away  of  scales,  surface  of  skin  would 
in  few  days  again  be  scaly. 

September  30 — Patient  walking  around  the  house,  good  appetite, 
constipated,  sleeps  well ;  dry,  scaly,  thickened  condition  of  skin  about 
the  same  as  has  been  for  two  weeks. 

Treatment :  Tonic  remedies,  as  iron,  quinine  and  strychnine,  etc., 
astringents,  bismuth,  etc.,  were  given  at  various  times  during  illness 
with  little  apparent  effect.    Diet  most  carefully  regulated, 

Atoxyl  given  for  six  weeks  by  mouth  in  one-third  grain  dose, 
four  times  a  day.  At  first  this  seemed  to  be  of  benefit,  but  later  of 
no  service  whatever. 

Later  began  atoxyl,  two-grain  doses  hyperdermically  every  four 
days  and  solution  of  arsenite  of  iron  sixteen  minims  daily  given 
hyperdermically — deep  injections.  This  is  the  treatment  (modified) 
of  Dr.  Wood,  of  Wilmington,  N.  C.  This  has  been  of  very  great 
help  to  this  patient.  He  is  stronger,  more  like  himself;  the  eruption 
is  fading.  Within  five  days  after  the  commencement  of  the  injec- 
tions of  arsenite  of  iron  a  different  expression  on  patient's  face,  more 
like  himself  in  every  way  and  began  to  improve  in  all  respects. 

Conclusions. 

I.  No  history  of  maize  diet  for  past  six  years.  This  food  product 
is  not  to  be  classed  as  cause  of  illness  of  this  patient. 

II.  Nothing  in  family  or  personal  history  or  habits  to  point  to  a 
cause  of  the  trouble. 

III.  The  history  indicates  the  trouble  to  have  commenced  two 
and  a  half  years  before  consulting  a  physician  for  treatment, 

IV.  Atoxyl  and  arsenite  of  iron  given  hyperdermically  were  the 
only  remedies  used  with  any  degree  of  benefit.  These  remedies  have 
greatly  relieved  the  unfavorable  conditions,  added  to  the  comfort 
and  strength  of  the  patient.  Whether  they  will  prove  a  cure,  time 
and  continued  use  can  only  tell. 


253 


REPORT  OF  A  SPORADIC  CASE  OF  PELLAGRA 

JOHN  LUNNEY,  M.  D. 

DAELINGTON,    S.    C. 

On  the  nth  day  of  August  last  I  was  called  to  see  a  young 
white  married  woman,  age  23,  named  Mrs.  C.  S.,  who  resided  at  the 
mill  village  in  close  proximity  to  the  town  of  Darlington,  She  was 
afflicted  with  what  appeared  to  me  a  very  mysterious  disease,  unlike 
anything  I  had  ever  seen  before  in  a  practice  of  over  forty  years. 

Symptoms. — The  symptoms  on  examination  revealed  a  slightly 
accelerated  pulse  and  a  temperature  not  exceeding  loi  degrees  F. 
There  was  a  squamous  eruption  on  the  forehead  and  face  as  far 
down  as  the  anterior  nares.  There  were  multiform  lesions  on  an 
inflamed  base  extending  all  around  the  neck,  shoulders,  arms,  fore- 
arms and  hands.  The  backs  of  the  hands  where  the  disease  origin- 
ally commenced  were  slightly  swollen.  The  upper  part  of  the  chest 
as  far  down  as  the  mammory  glands  was  also  involved  in  the  trouble. 
The  affected  parts  were  covered  with  papules,  fine  vescicles,  scales, 
scabs  and  crusts  with  a  secretion  of  pus  under  some  of  the  scabs.  In 
front  the  neck  had  a  glazed  appearance.  The  tip  and  edges  of  the 
tongue  and  mouth  were  ulcerated  and  bled  a  little  occasionally.  The 
nasal  passages  were  also  ulcerated  and  inflamed.  The  disease  evi- 
dently extended  through  the  whole  alimentary  canal  and  other 
mucous  passages.  There  was  considerable  salivation  with  expectora- 
tion of  a  bluish,  foamy,  watery  discharge.  During  the  latter  part 
of  her  illness  a  towel  had  to  be  placed  under  the  side  of  her  head  to 
absorb  it.  The  eruption  was  so  severe  and  painful  that  the  patient 
had  to  sit  in  a  rocking  chair  day  and  night  until  within  a  few  days 
of  her  death,  when,  from  sheer  exhaustion,  she  had  to  lie  down. 
There  was  complete  anorexia,  loose  bowels,  loss  of  flesh  and  a 
neurasthenic  condition  amounting  to  melancholia  which  persisted  to 
the  last.  On  the  lower  extremities  there  were  small  scaly  spots,  and 
also  small  purpuric  spots  extending  down  to  the  ankles. 

Etiology. — The  etiology  of  this  disease  is  still  a  matter  suh  judice. 
It  is  supposed  to  be  brought  about  by  the  ingestion  of  spoiled  maize 
as  an  article  of  food.  When  corn  products  become  decomposed  by 
fungi,  fermentation  or  otherwise,  poisonous  properties  are  devel- 
oped which  probably  bring  on  ptomaine  poisoning.  There  are 
doubtless  other  contributory  factors  in  the  causation  of  the  disease, 
which,  as  yet,  are  not  fully  understood.     Formerly  the  disease  was 


254 

found  in  Italy,  France,  Spain,  Roumania  and  other  countries.  It  is 
now,  however,  becoming  alarmingly  frequent  in  this  country.  Dr. 
J.  W.  Babcock,  physician  and  superintendent  of  the  State  Hospital 
for  the  Insane  at  Columbia,  S.  C,  together  with  Dr.  J.  J.  Watson, 
recently  visited  Italy  for  the  purpose  of  studying  pellagra,  and  to 
their  intelligent  investigations  we  are  indebted  for  a  clearer  insight 
into  the  disease.  The  investigations  of  Dr.  C.  H.  Lavinder,  of  the 
Public  Health  and  Marine  Hospital  Service,  have  also  thrown  a  good 
deal  of  additional  light  on  this  hitherto  obscure  malady.  Cases  of 
this  disease  have  have  been  found  in  South  Carolina,  Georgia,  Ala- 
bama, Florida,  Tennessee,  Texas,  North  Carolina,  Arkansas,  Illinois, 
and  other  States. 

Pathology. — In  most  cases  the  degenerative  changes  which  take 
place  are  caused  by  the  deleterious  influence  of  the  toxins  developed 
in  the  system  during  the  progress  of  the  disease,  the  nature  of  which, 
as  yet,  is  not  fully  understood. 

Diagnosis. — The  diagnosis  to  one  who  had  never  seen  a  case  of  the 
kind  before,  is  quite  difficult.  In  this  case  (my  first)  I  had  to  arrive 
at  a  diagnosis  by  exclusion ;  that  is,  I  had  to  find  out  what  the 
disease  was  by  finding  out  what  it  was  not.  I  compared  the  symp- 
toms and  lesions  with  other  well  known  skin  diseases  and  found 
that  they  did  not  coincide  with  anything  that  I  had  previously  seen. 

Treatment. — In  this  case  the  constitutional  treatment  consisted  of 
liquid  food  with  stimulants,  quinine,  iron,  strychnine,  arsenic,  nasal 
douches,  mouth  washes  and  gargles  of  glyco-thymoline  properly 
diluted.  The  first  thing  I  did  was  to  thoroughly  cleanse  the  surface, 
(which  had  been  covered  with  gunpowder),  with  castile  soap  and 
warm  water  followed  by  a  thorough  further  cleaning  and  disinfection 
with  liquid  green  soap,  and  afterwards  powdering  the  raw  surface 
with  boric  acid.  The  remedy  that  relieved  the  burning  pain  best  was 
a  preparation  of  equal  parts  of  linseed  oil  and  lime  water  with  40 
drops  of  carbolic  acid  added  to  the  pint.  This  was  more  soothing 
to  the  skin  lesions  and  gave  the  patient  more  ease  and  comfort  than 
any  other  remedy  employed.  The  case  terminated  fatally  from 
exhaustion  on  September  i,  1909;  that  is,  21  days  after  I  first  saw 
her,  notwithstanding  my  best  efforts  to  save  her.  All  through  the 
disease  she  was  gloomy,  sad  and  depressed  and  said  she  was  going  to 
die.  This  was  the  first  case  of  this  kind  that  ever  occurred  in  this 
county  that  I  am  aware  of.  I  deemed  it  of  sufficient  interest  to 
report  it  to  the  Darlington  County  Medical  Society  at  our  last  meet- 
ing on  September  30,  1909. 


255 


REPORT  OF  EIGHT  CASES  OF  PELLAGRA 

THEODORE  MADDOX,  M.  D. 
UNION,    s.    c. 

On  receiving  the  preliminary  program  I  saw  that  there  were  many 
interesting  dissertations  to  be  presented  for  your  consideration,  with 
the  time  rather  Hmited,  so  I  requested  that  I  be  permitted  to  with- 
draw, but  Dr.  Babcock  insisted,  so  I  shall  direct  your  attention  to  a 
report  on  eight  cases  coming  under  my  observation  during  the  past 
few  months. 

Case  I.  T.  P.  M.,  male,  age,  60.    Occupation,  farmer. 

I  saw  the  patient  for  the  first  time  on  June  9,  1906. 

History:  Bilious  attacks  accompanied  with  diarrhoea  during  the 
early  spring  months  for  at  least  eight  years,  which  had  gradually 
grown  worse,  but  this  was  the  first  time  patient  had  been  confined  to 
his  bed. 

On  examination  I  found  the  patient  extremely  bilious,  very  nerv- 
ous, moderate  temperature,  severe  headache,  pains  in  extremities, 
diarrhoea,  vertigo  on  rising,  sore  mouth,  tongue  very  red,  with  com- 
plete loss  of  epithelium,  nausea  and  vomiting. 

During  the  subsequent  twelve  days  the  temperature  gradually  in- 
creased until  it  reached  103  F.  during  forenoon,  and  104  F.  in  the 
afternoon;  occasionally,  however,  during  this  time  there  occurred 
rapid  fluctuations  in  temperature,  which  was  thought  at  the  time  to 
indicate  a  malarial  complication. 

From  June  20th  to  July  loth  the  patient's  condition  was  considered 
very  critical,  all  the  symptoms  having  increased  in  severity  until  death 
seemed  only  a  question  of  a  few  hours.  At  this  time  there  was  pro- 
nounced delirium,  and  during  rational  moments  suicidal  mania. 

The  stools  resembled  those  of  typhoid,  the  odor  was  extreme,  and 
blood  occurred  very  early. 

While  the  diagnosis  was  typho-malaria,  still  I  was  not  satisfied,  for 
I  felt  that  there  was  something  more  in  the  case. 

The  following  spring  the  patient  -had  an  attack  similar,  but  much 
less  severe  than  the  previous  one. 

During  the  past  spring  the  patient  had  only  the  vertigo,  darting 
pains  in  the  head  and  mild  gastro-intestinal  disturbance. 

•Each  spring  since  coming  under  my  observation  the  patient  has 
had  the  characteristic  symmetrical  pellagrous  lesions  on  the  hands. 


256 

These  were,  in  1906,  supposed  by  the  writer  to  have  been  due  to  the 
action  of  the  actinic  sun  rays  on  a  very  much  debilitated  skin. 

With  the  discovery  of  pellagra  in  South  Carolina  it  was  an  easy 
matter  to  make  a  diagnosis  in  this  case,  as  pellagra  often  resembles 
typhoid. 

Treatment :  Guaiacol  Carb,  quinine  and  arsenic  were  the  princi- 
pal drugs  used  in  this  case. 

Case  2.  Miss  L.  M.,  female,  single,  age,  25.  Occupation,  stenog- 
rapher. 

This  was  the  most  typical  type  of  the  spirilla  pellagra^  1  have  ever 
seen. 

I  saw  her  first  June  14,  1909.  Chief  complaint,  diarrhoea  and  irreg- 
ular menstruation. 

History:  About  thirteen  years  previous  she  had  suffered 
severely  with  diarrhoea  during  the  early  spring.  Had  had  periodic 
attacks  during  each  succeeding  spring,  which  increased  gradually  in 
severity.  On  returning  from  a  visit  to  the  Isle  of  Palms  during  the 
summer  of  1908,  the  characteristic  pellagrous  eruption  occurred  on 
hands,  face  and  neck,  with  decided  nervous  symptoms,  vertigo  and 
gastro-intestinal  disturbances.  Recovery  at  this  time  was  very 
tedious ;  she  had  more  or  less  vertigo,  nervousness  and  gastro-intes- 
tinal disturbance  all  through  the  winter,  and  early  in  the  spring  there 
was  an  exacerbation,  about  two  weeks  after  which  I  was  called. 

Examination :  Uncontrollable,  occasionally  slightly  bloody  diar- 
rhoea, sore  mouth,  very  red,  clean  tongue,  with  loss  of  epithelium; 
irregular  menstruation  occurring  anywhere  from  two  to  four  weeks, 
pronounced  anemia,  very  nervous,  vertigo,  photophobia,  marked  de- 
bility, loss  of  memory,  pronounced  anorexia,  languid,  morose,  de- 
spondent, discouraged,  insomnia,  reflexes  extreme,  especially  vaginal. 

She  was  given  the  usual  remedies  for  gastro-intestinal  disturb- 
ances, but  recovery  was  tedious.  In  two  weeks  she  felt  well  enough 
to  return  to  her  work.  I  saw  her  on  the  following  day,  as  she  was 
not  doing  quite  so  well.  At  this  time  I  observed  the  symmetrical 
lesions  on  hands,  which  had  occurred  while  walking  from  her  resi- 
dence to  the  office,  a  distance  of  four  blocks.  It  occurred  to  me  that 
these  lesions  were  too  severe  for  the  distance  traveled  and  time 
exposed,  also  their  symmetry  caused  me  to  consider  the  case  more 
carefully.  At  this  time  it  occurred  to  me  that  she  was  a  pellagrin, 
and  her  father  and  brother  were  so  informed. 

Inasmuch  as  I  had  never  seen  a  pellagrin,  I  advised  that  Dr.  Bab- 


257 

cock  be  called  in  consultation.  This  not  being  convenient  at  the  time, 
patient  was  placed  on  Atoxyl  and  Blaud. 

In  July  the  uterine  hemorrhage  became  so  severe  that  she  was 
given  the  usual  acid  drink,  without  any  appreciable  benefit,  after 
which  ergot  was  tried  with  the  same  negative  result. 

Early  in  August  her  condition  became  very  alarming.  On  August 
9th  patient  was  anesthetized  and  curettage  performed  with  the  hope 
of  checking  hemorrhage.  The  os  uteri  was  found  soft,  flabby  and 
patent,  and  the  endometrium  was  loaded  with  debris.  Immediately 
following  this  slight  operation  improvement  was  very  rapid  and 
decided,  and  it  appeared  to  the  inexperienced  that  she  would  soon  be 
restored  to  perfect  health. 

During  September  she  suffered  a  relapse.  Not  only  did  the  old 
symptoms  recur  with  increased  severity,  but  excruciating  pains 
developed  in  the  lumbar  region  and  extremities.  Spinal  lesions  were 
doubtless  occurring  at  this  time. 

Suicidal  mania,  with  a  loss  of  confidence  in  attendants,  was  at  this 
time  occasionally  manifested. 

Forty-eight  hours  before  death  symptoms  similating  meningitis 
occurred.  Muscular  contractions  of  spine  and  extremities  were  very 
marked.  Although  narcosis  was  complete,  opis-thotonus  was  ex- 
treme. Occasionally  at  short  intervals  I  had  the  nurse  to  bring  the 
patient  to  a  semi-narcosis,  during  which  time  there  occurred  the 
most  pitious  ravings  and  horrible  seizures. 

According  to  current  literature,  this  is  the  spirilla  type  of  pellagra. 

Case  3.  Mrs.  H.,  age,  50,  married.    Multipara. 

Called  to  see  patient  for  the  first  time  May  25,  1909. 

Principal  Complaint :  Indigestion  with  frequent  attacks  of  diar- 
rhoea. 

History :  For  the  past  twelve  or  fourteen  years  had  suffered  with 
a  chronic  gastro-intestinal  disturbance,  with  frequent  exacerbations, 
especially  during  the  spring  and  autumn  months,  which  gradually 
have  increased  in  severity,  until  now  she  is  unable  to  perform  any  of 
her  household  duties. 

Examination :  Sore  mouth,  very  red  tongue,  with  prominent 
papillse,  and  complete  loss  of  epithelium,  photophobia,  vertigo,  fleet- 
ing pains  in  head  more  or  less  all  the  time,  but  were  increased  in 
severity  during  the  spring  and  autumn  months;  usually  diarrhoea 
with  an  occasional  bloody  stool,  occasionally  contipated,  during 
which  time  there  was  much  flatus  and  discomfort,  which  caused  an 
increase  in  severity  of  all  the  symptoms. 

17— P.  C. 


258 

Emaciation,  anemia  and  anorexia  were  very  pronounced. 

Treatment :  Inasmuch  as  the  gastro-intestinal  disturbance  was  the 
most  complained  of,  as  well  as  the  most  prominent  symptom,  she 
was  given  test  breakfast  of  Ewald-Boas,  consisting  of  a  breakfast 
roll  and  a  glass  and  a  half  of  water.  An  hour  later  an  effort  was 
made  to  evacuate  stomach  contents.  As  undigested  particles 
would  occlude  lumen  of  tube,  only  ten  C.  C's.  could  be  withdrawn. 

Examination  of  Contents : 

Digestion,  practically  nothing. 

Consistency,  bread  and  water. 

Expressed  contents,  lo  C.  C's. 

Residual  contents,  not  estimated. 

Mucous,  X. 

Appearance,  bread  and  water. 

Free  HCi.,  nothing. 

Acidity  of  contents,  lo. 

Combined  acidity,  not  estimated. 

Acidity  of  washings,  not  estimated. 

Organic  acids,  acetic. 

Odor,  yeast. 

Relative  quantity  of  solid  and  liquid  portions,  half  and  half. 

Owing  to  small  quantity,  expressed  ferments  were  not  estimated  at 
this  time. 

There  being  a  large  quantity  of  mucous  present,  and  a  complete 
failure  of  digestion,  she  was  given  antiseptics  and  the  bitter  tonics 
in  order  to  increase  digestion  so  that  a  larger  quantity  could  be  ex- 
pressed later  and  a  more  thorough  examination  of  the  contents  made. 

Lesions  occurring  on  the  hands  within  a  few  days,  a  diagnosis  of 
pellagra  was  made,  the  patient  considered  hopeless  and  a  further 
examination  unnecessary.  She  was  placed  on  Fowler's  solution  for 
a  short  time,  then  Atoxyl  and  Blaud.  These  remedies  were  given 
for  a  period  of  twenty  days,  then  an  intermission  of  ten  days. 

The  patient  has  neither  lost  or  gained  to  any  appreciable  extent 
since  coming  under  my  observation. 

Case  4.  Mrs.  N.  K.,  age,  38 ;  married ;  six  children.  Occupation, 
domestic. 

Saw  her  for  the  first  time  October  10,  1909.  Chief  complaint, 
nervousness,  indigestion,  diarrhoea. 

History :  Has  been  in  poor  health  for  a  long  time,  but  noticed  that 
she  suffered  more  in  the  spring  and  autumn,  and  especially  has  she 
suffered  during  her  past  three  parturient  periods,  which  occurred  in 


259 

1905,  1906,  and  1908  respectively.  She  said  that  it  would  be  utterly 
impossible  for  her  to  describe  her  sufferings  during  these  periods, 
and  that  she  prayed  constantly  that  she  should  never  again  go 
through  another.  She  has  been  growing  gradually  worse  during  the 
past  four  or  five  years. 

Examination:  Characteristic  symmetrical  pellagrous  lesions  on 
hands,  arms,  sides  of  neck  and  across  lower  portion  of  nose ;  vertigo, 
headache,  indigestion,  bloody  diarrhoea;  appetite  poor,  anemia, 
nervousness ;  occasionally  constipation. 

Treatment :  Atoxyl  and  Blaud  principal  remedies  used.  Decided 
improvement. 

Case  5.  J.  P.,  female;  aged,  35;  colored;  single.  Occupation, 
domestic. 

Applied  for  treatment  on  April  16,  1909;  wanted  to  know  if  she 
did  not  have  the  new  disease. 

History :  Lesions  first  occurred  on  hands  in  1908.  She  has  been 
growing  gradually  worse  since. 

Examination :  Characteristic  symmetrical  pellagrous  lesions  on 
hands  and  arms ;  periodic  attacks  of  indigestion  and  diarrhoea,  which 
is  occasionally  bloody;  vertigo,  fleeting  pains  in  head,  red  tongue 
with  prominent  papillae  and  partial  loss  of  epithelium,  anorexia  and 
anemia. 

Treatment :    Blaud  and  Atoxyl. 

Case  6.  W.  G.,  age,  34;  male;  married.  Occupation,  mill  opera- 
tive. 

Applied  for  treatment  September  26,  1909.  Complaining  with 
weakness  and  diarrhoea. 

History :  Health  had  been  gradually  failing  for  the  past  year  or 
more,  but  diarrhoea  had  occurred  only  about  two  months  previous. 
Had  gone  the  usual  rounds  at  the  drug  stores,  and  during  the  past 
month  had  been  under  the  care  of  two  physicians  at  different  times 
without  any  appreciable  benefit,  except  to  get  diarrhoea  checked,  dur- 
ing which  period  he  was  considerably  worse.  I  would  like  to  state 
that  this  has  been  so  with  all  my  cases.  They  would  be  very  miser- 
able until  diarrhoea  recurred. 

Examination :  Uncontrollable  bloody  diarrhoea,  mild  headaches, 
slight  vertigo,  chronic  gastritis,  sore  mouth,  red  tongue  slightly  de- 
nuded; much  debility,  anemia,  anorexia,  emaciation  and  much 
drowsiness. 

Treatment :    Guaiacol  Carb.  et  Atoxyl.    Recovery  very  rapid. 

Case  7.    N.  M.,  female ;  age,  20.    Occupation,  school  teacher. 


26o 

Applied  for  treatment  September,  1909,  complaining  with  a  gas- 
tro-intestinal  disturbance. 

History :  Had  been  well  until  some  six  or  eight  weeks  previously. 
At  this  time  she  had  a  severe  bihous  attack,  with  the  usual  malaise ; 
headache,  vertigo,  drowsiness  and  impairment  of  appetite.  Periodic 
attacks  of  diarrhoea,  with  constipation  during  the  interim,  during 
which  time  all  symptoms  were  increased  in  severity. 

Examination :  Mild  pyrexia,  diarrhoea,  sore  mouth,  red  tongue, 
indigestion  with  much  flatus. 

Diagnosis :  Simple  biliousness. 

Treatment:  Eliminative  and  antiseptic.  Recovery  was  tedious 
and  incomplete.  Within  a  few  days  there  was  an  exacerbation,  at 
which  time  pellagra  was  suspected  and  patient  given  Guaiacol  Carb. 
et  Atoxyl.  Recovery  rapid  and  seemingly  complete.  Her  rosy 
cheeks  returned  and  she  not  only  regained  lost  weight,  but  now 
weighs  several  pounds  more  than  at  any  previous  time  during  life. 

Case  8.  Mrs.  W. ;  age,  32 ;  married ;  prinupera.  Occupation, 
housewife. 

I  saw  her  for  the  first  time  November  3,  1909,  at  9  A.  M. 

History :  Has  suffered  since  her  fourteenth  year  with  rheumatism 
and  dysmenorrhoea.  About  ten  years  ago  ovaritis  occurred.  During 
a  period  extending  from  1902-6  three  os  uteri  dilitations  were  per- 
formed with  negative  result.  In  1907  abdominal  section  was  per- 
formed with  removal  one-third  1.  ovary.  Improvement  temporary. 
Indigestion  during  the  past  twelve  years.  Early  in  September,  1908, 
she  had  an  attack  similar  to  the  present  one,  since  which  time  there 
has  occurred  periodic  attacks  of  mania.  She  has  been  under  medical 
treatment  more  or  less  during  the  past  eighteen  years,  and  during 
the  past  two  years  continuously  under  treatment. 

Examination :  Sore  mouth  with  scalded  burning  sensation  ex- 
tending from  lips  to  stomach,  tongue  red,  with  prominent  papillae 
and  loss  of  epithelium  extending  along  its  border;  reflexes  exagger- 
ated ;  insomnia,  photophobia,  anorexia,  pains  in  head  and  mild  consti- 
pation ;  pellagrous  lesions  on  hands. 

Vaginal  Examination :  Extreme  hyperesthesia,  fiery  redness, 
vesicles  on  vulva  extending  to  rectum  with  tendency  to  pustulation. 
Examination  rectum  same  as  vagina. 

In  conclusion  will  state  that  an  early  diagnosis  in  pellagra  stands 
in  importance  next  to  preventive  medicine. 

If  the  disease  is  curable  at  all  it  is  prior  to  the  occurrence  of  the 
lesions,  for  at  this  time  the  nervous  system  is  irreparably  damaged. 


26l 


IS  PELLAGRA  COMMUNICABLE  OR  HEREDITARY? 

H.  H.  GRIFFIN^  M.  D. 

Assistant  Physician,   State  Hospital  for  Insane 

COLUMBIA,  s.  c. 

Medical  opinion  in  Italy  seems  to  be  unanimously  against  the 
theory  that  pellagra  is  contagious  or  infectious.  As  the  question, 
however,  is  today  one  of  the  most  frequent  brought  to  the  attention 
of  the  general  practitioner,  and  asylum  physicians,  I  thought  it 
worth  while  to  review  this  particular  phase  of  the  pellagra  problem, 
and  I  do  this  more  particularly  because  of  the  action  of  the  health 
authorities  of  certain  States  that  pellagra  cases  should  be  isolated. 

To  begin  with,  let  me  call  to  your  attention  the  summary  of  the 
opinion  generally  entertained  in  Italy,  about  pellagra  as  given  by 
Tanzi,  who  observes :  "In  short,  pellagra  is  a  disease  of  man  and 
other  vertebrates  which  in  turn  is  derived  from  a  disease  of  Indian 
corn.  The  disease  of  the  animals  is  an  intoxication,  that  of  the 
maize  is  an  infection,  the  parasites  of  maize  is  not  infective  in  ani- 
mals." 

All  of  us  who  have  studied  available  literature,  and  it  may  be  one 
hundred  or  more  cases,  must  admit  that  as  yet  we  Americans  are  not 
in  a  position  to  dogmatize  about  pellagra.  We  constantly  see  cases 
which  raise  the  question  of  its  communicability  whereas  usually 
only  one  case  develops  in  a  family,  yet  instances  have  previously 
and  during  this  Conference,  been  reported  in  which  several  mem- 
bers of  the  same  family  have  developed  pellagra.  The  members  of 
a  family  are  generally  placed  under  exactly  similar  circumstances, 
those  very  ones  which  probably  engender  the  disease.  Furthermore, 
unquestionably,  cases  of  pellagra  develop  in  asylums  in  patients 
who  have  been  long  residents  therein  who  have  undoubtedly  been 
associated  with  pellagrins,  so  it  is  pertinent  and  important  not  only 
to  ask,  but  to  determine  the  origin  of  this  pellagrous  syndrome.  Un- 
fortunately the  very  large  proportion,  if  not  all  of  the  cases,  have 
eaten  products  of  Indian  corn.  So  that  unless  we  deny  in  toto  the  in- 
fluence of  maize  as  a  probable  cause  of  pellagra,  we  are  forced  to 
consider  it  as  a  possible  factor. 

A  most  admirable  study  of  pellagra  by  Nicolas  and  Jambon  of 
Lyons,  France,  concludes  that  pellagra  attacks  three  classes  of  in- 
dividuals, namely: 


262 

1.  Those  who  eat  corn.  The  malady  here  arising  from  the  poor 
food. 

2.  The  insane.  The  pellagrous  syndrome  in  these  cases  being  as- 
signed to  psychic  depression.  (As  well  as  the  food  ration). 

3.  Those  coming  under  neither  of  these  groups — "sporadic"  cases 
and  "pseudo-pellagra,"  in  which  alcoholism  is  the  most  common  con- 
tributing factor, 

Sandwith  calls  pellagra  non-contagious  in  his  definition  of  the 
disease.  He  further  says  that  he  is  not  converted  to  the  Italian  be- 
lief that  pellagra  is  hereditary,  excepting  in  the  way  that  alcoholism 
is  now  believed  to  be  so.  Calderini  noticed  in  184  familes  compris- 
ing 1,319  members,  inheriting  predisposition,  that  648  were  diseased, 
671  healthy,  practically  equally  divided. 

Says  Nicolas  and  Jambon :  "The  hypothetic  role  of  heredity 
admitted  by  Strambio  and  Calderini  was  proven  false  by  Roussel  and 
Bouchard,  false  so  far  as  including  the  transmission  of  a  germ  from 
parents  to  their  children.  But  if  by  heredity  one  means  only  a 
debility  of  constitution  of  pellagrous  infants,  their  pathological  pre- 
disposition, this  hypothesis  is  tenable  and  is  verified  by  observers  in 
countries  where  pellagra  is  frequent.  (Here  we  might  draw  the 
parrallelism  between  pellagra  and  tuberculosis). 

"Bouchard  admits  a  morbid  tendency,  a  predisposition  and  further 
says  this  predisposition  is  of  less  importance  without  exposure  to  the 
sun  and  poverty  without  which  it  would  be  incapable  of  itself  of  pro- 
ducing pellagra." 

Scheube  (disease  of  warm  countries)  says  heredity  plays  a  part 
in  the  etiology  of  the  disease,  as  the  acquired  predisposition  of  the 
nervous  system  to  contract  pellagra  can  be  transmitted  to  posterity, 
Lombroso  is  even  of  the  opinion  that  the  disease  itself  is  hereditary, 
especially  from  the  grand-parents.  (Here  evidently  atavism  is  a 
more  important  factor  in  producing  pellagra  than  immediate  here- 
dity). 

Further  studies  of  etiology  have  appeared  to  show  heredity  predis- 
position. 

The  investigation  of  Probizer  among  school  children  shows  the 
offspring  ot  parents  afflicted  with  pellagra  to  be  quite  generally 
of  poor  development,  both  physical  and  mental.  They  are  usually 
anemic  and  subject  to  various  nervous  and  digestive  disorders  as 
headache,  dullness,  listlessness,  dyspepsia,  gastralgia,  enteralgia, 
nausea  and  vomiting. 

The  mental  symptoms  manifest  themselves  especially  at  puberty. 


263 

(R.  A.  C.  Wollenberg,  Assistant  Surgeon  U.  S.  P.  H.  &  M.  H.  Ser- 
vice on  pellagra  in  Italy.) 

The  disease  is  sometimes  hereditary,  the  children  of  generations  of 
pellagrins  are  frequently  feeble  in  resistance  and  of  lowered  physi- 
cal vitality  and  hence  fall  easy  victims  to  the  disease.   (Marie). 

From  Babes  and  Sion  I  further  quote :  "Lombroso  distinguishes 
two  forms  of  hereditary  pellagra :  a  somewhat  more  severe  form  and 
a  very  mild  form.  This  is  so  far  interesting  as  it  deals  with  the  so- 
called  abortive  forms,  which  Roussel  will  not  recognize  as  pellagra 
In  such  cases  Lombroso  found  bad  formation  of  the  skull,  extraor- 
dinary brachia-cephalia  or  dolicho-cephalia,  retreating  forehead,  bad 
setting  of  the  external  ears,  asymetry  of  the  face,  anomalies  of  the 
genital  organs,  many  of  them  showing,  according  to  Lombroso,  a 
true  pellagra  sine  pellagra,  in  that  they  are  merely  single  symptoms, 
as  burning  of  the  feet,  pains  in  the  back,  leucorrhea,  amenorrhea, 
vertigo,  etc.,  while  desquamation  and  delria  are  wanting. 

"We  can  not,  however,  unconditionally  approve  of  this  view." 
We  have  not  ourselves  observed  anything  similar  and  it  is  difficult 
to  refer  such  vague  symptoms  to  a  disease,  which  is  characteristic  in 
its  entire  symptom-complex.  Only  in  such  places  where  misery, 
heredity  and  nourishment  with  spoiled  maize  are  shown  to  exist,  can 
we  assume  that  the  injurious  poisons  cause  some  of  the  pellagrous 
symptoms,  whereas  we  would  by  no  means  recognize  pellagra  cases 
with  such  single  symptoms  in  places  where  pellagra  is  not  found, 
and  maize  is  not  eaten. 

'Tn  the  pellagra  of  small  children  exists  probable  always  a  con- 
genital or  hereditary  element  to  which  the  poor  nourishment  and 
neglect  make  an  essential  contribution. 

"It  was  indeed  early  recognized  and  especially  emphasized  by 
Lombroso  that  cretins  and  epileptics  are  predisposed  by  nature  to 
pellagra." 

Predisposing  causes — Innate  weakness  as  manifested  in  cretins 
and  epileptics,  and  influence  inherited  from  drunkards,  pellagrins, 
syphilitics,  and  malarial  ancestry. 

These  conditions  involve  the  nervous  system  so  that  in  the  next 
and  succeeding  generations  this  vulnerability  is  even  more  marked. 

Sambon  says  pellagra  is  not  transmitted  by  means  of  lactation.  He 
further  says :  Until  quite  recently,  the  majority  of  physicians  believed 
in  the  hereditary  transmission  of  pellagra.  Contagion  was  not 
admitted  but  cases  of  conjugal  pellagra  have  been  reported. 

Procopiu  discusses  at  length  both  of  my  queries.    He  says : 


264 

"The  non-contagion  of  pellagra  is  proven.  The  contrary  opinion 
has  been  sustained  by  Saloman,  Titius,  Hameau  and  Casal.  The 
peasantry  who  live  in  towns  and  come  in  intimate  contact  with  an 
urban  population  have  never  exhibited  tKe  appearance  of  a  single 
case  of  pellagra;  furthermore  the  people  who  live  in  the  country 
among  pellagrins,  but  without  using  corn  for  nourishment  never 
become  pellagrous  themselves.  Boniva  has  tried  to  inoculate  this 
disease  with  the  blood  and  with  the  saliva,  but  without  result.  All 
these  facts  prove  that  pellagra  is  not  contagious,  as  would  be 
expected  since  it  is  an  intoxication." 

This  non-contagion  is  an  argument  against  the  microbian  theory 
of  pellagra. 

Heredity — The  heredity  of  pellagra  has  been  sustained  by  Odoardi, 
Calderini,  Landouzy,  Ballardini  and  a  number  of  others. 

"Pellagra  is  not  hereditary  although  children  of  pellagrins  develop 
it  frequently.  One  almost  never  sees  pellagrous  nurslings.  The 
children  of  pellagrins,  if  they  do  not  eat  corn,  never  become  pel- 
lagrous, but  the  influence  of  pellagra  makes  itself  felt  from  genera- 
tion to  generation  becoming  for  the  race  a  real  cause  for  degeneracy. 

"Boudin  rightly  says :  'Pellagrins  transmit  to  their  children  an 
evident  predisposition  to  this  malady.  This  predisposition  shows 
itself  by  their  inferior  physique  which  lessens  their  resistance  to  the 
toxin.  If  many  members  of  a  family  are  attacked,  the  fact  is  very 
natural,  all  being  exposed  to  the  same  cause.'  " 

Sacchi  says :  "The  offspring  of  pellagrins  are  recognized  by  their 
uncertain  gait,  by  their  yellowish  eyes,  by  their  jaundiced  complexion, 
by  their  fissured  lips,  by  their  coarse  hair,  by  their  puny,  dull  and 
apathetic  appearance. 

"Lombroso  specifies  predisposition  to  microcephaly,  the  absence  of 
hair,  atrophy  of  the  genital  organs  and  the  hypertrophy  of  the 
abdominal  ganglia. 

"We  have  met  with  microcephalic  offspring  of  pellagrins,  but  we 
have  not  noticed  the  absence  of  hair,  on  the  contrary,  we  have  some- 
times marked  its  abundance.  We  have  seen  idiots  born  of  pellagrous 
parents,  and  also  dwarfs  and  cretins. 

"Ordinarily  the  children  of  pellagrins  are  anemic  and  apathetic. 
Boudin  believes  that  if  the  father  is  pellagrous,  the  predisposition  to 
pellagra  is  transmitted  to  the  boys,  and  a  pellagrous  mother  trans- 
mits this  predisposition  to  the  girls.  He  supports  this  affirmation 
by  a  table  of  cases  of  pellagra  which  he  had  met  in  Italy,  This 
assertion  has  not  since  been  confirmed." 


265 

The  Italian  school  denies  the  communicability  of  pellagra,  but 
admits  that  the  descendants,  especially  the  grandchildren,  of  pel- 
lagrins are  particularly  susceptible  to  the  unknown  poison.  In  the 
face  of  long  years  of  observation  by  innumerable  observers,  such 
evidence  is  not  lightly  to  be  set  aside.  What  American  would  pre- 
sume after  a  few  years  study  of  a  limited  number  of  cases,  to  set  up 
his  opinion  against  Lombroso,  who  said  that  he  had  studied  pellagra 
all  his  life.  He  certainly  had  studied  it  for  forty  years  in  Lombardy, 
and  who  shall  undertake  to  estimate  the  number  of  cases  he  saw  dur- 
ing this  long  period.  While  the  French  school  does  not  admit  the 
theory  of  communicability,  they  seem  especially  inclined  in  explain- 
ing their  cases  of  "pseudo-pellagra"  and  "sporadic"  pellagra  to  em- 
phasize the  influence  of  heredity  and  the  role  of  alcoholism. 

The  German  and  Roumanian  schools,  if  one  may  conclude  from 
Babes  and  Sion,  agree  in  the  main  with  the  Italians. 

I  draw  briefly  two  conclusions,  namely: 

1.  That  pellagra  is  not  communicable,  basing  this  conclusion  upon 
the  authority  of  many  great  minds  who  have  spent  a  lifetime  in  the 
study  of  this  disease.  This  seems  to  be  the  universal  conclusion  of 
those  who  by  virtue  of  a  large  experience  are  in  a  position  to  speak 
and,  from  the  one  hundred  or  more  cases  that  have  come  under  the 
observation  of  the  staff  of  this  institution. 

2.  That  pellagra  is  hereditary — that  is  in  the  form  of  a  predis- 
position or  a  morbid  tendency,  such  a  tendency  as  we  now  believe 
to  be  inherited  in  tuberculosis  or  even  in  insanity  itself. 

The  hereditary  pellagrin  is  especially  vulnerable,  not  only  to  pel- 
lagra but  as  well  to  physical  and  mental  degeneration,  including 
insanity. 

Granting  this  double  hereditary  weakness  as  proven  to  exist  in 
the  offspring,  that  is  the  children,  and  especially  the  grandchildren 
of  pellagrins — and  further  admitting  as  proven  the  prevalence  of 
pellagra  in  our  country  among  the  white  and  black  races  today  and 
possibly  existing  for  thirty  or  forty  years  past,  are  we  not  brought 
face  to  face  with  a  tangible  explanation  of  the  reason  for  the  prev- 
alence of  insanity  today  especially  the  increase  of  mental  disease 
that  has  been  steadily  going  on  in  the  negro  race  since  emancipa- 
tion? If  the  pellagrous  heredity  from  the  past  is  a  factor  in  pro- 
ducing insanity  today,  what  have  yoii,  the  medical  members  of  this 
conference,  the  guardians  of  the  public  health  in  many  common- 
wealths, to  say  is  one  of  the  most  tangible  means  of  preventing  in- 
sanity for  the  future?     There  can  be  but  one  answer,  "Establish 


266 

beyond  doubt  the  real  cause  of  pellagra  and  remove  it,  and  save 
humanity  from  two  of  its  greatest  curses :  pellagra  and  its  congener, 
insanity." 

It  has  been  well  said  by  Dr.  Zeller :  "When  we  know  what  pellagra 
is  we  shall  be  much  nearer  understanding  what  insanity  is." 


DISCUSSION  ON  THE  PAPER  OF  DR.  GRIFFIN 

Dr.  John  Forrest,  of  Charleston,  S.  C. :  If  I  may  be  allowed  to 
express  my  opinion  on  this  subject  I  should  say  that  pellagra  is 
neither  contagious  nor  hereditary  any  more  than  any  specific  poison 
is,  any  more  than  ergotism  is,  and  indeed  the  analogy  between 
ergotism  and  pellagra  is  remarkable,  although  not  a  word  has  been 
said  here  with  regard  to  the  analog\^  between  these  two  conditions. 
I  have  heard  it  said  on  the  floor  today  that  corn  is  not  the  cause  of 
pellagra.  I  did  not  suppose  anybody  thought  it  was.  Corn  is  not 
corn  when  it  is  poisoned,  it  is  not  corn  when  it  is  damaged,  it  is 
not  corn  when  it  has  turned  into  fungus,  neither  is  rye.  Who  ever 
heard  of  ergotism  being  charged  to  eating  rye?  You  may  eat  as 
much  rye  as  you  please  and  never  be  poisoned,  but  if  you  eat  ergot, 
which  is  a  fungus  that  replaces  the  grain  of  rye,  you  will  be  poisoned, 
and  as  ergot  is  the  cause  of  ergotism,  so,  a  fungus  replacing  the 
grain  of  corn  is,  I  believe,  the  cause  of  pellagra.  Almost  all  fungi 
are  poisonous,  and  if  we  want  to  get  at  the  true  cause  of  this  disease 
we  must  study  the  corn  itself  that  is  damaged  and  that  has  taken  on 
a  fungus  growth. 

Dr.  Watson  (closing  the  discussion)  :  In  this  institution  (South 
Carolina  State  Hospital  for  the  Insane)  it  has  been  observed  that 
the  nurses  can  make  a  diagnosis  of  pellagra  before  the  skin  eruption 
appears  by  the  offensive  odor  and  characteristic  appearance  of  the 
stools. 


267 


PELLAGRA  IN  CHILDREN 

M.    B.    YOUNG 

EOCK  HILL,   S.   C. 

Dr.  Lavinder  has  said  that  the  task  remains  to  the  Southern 
physician  to  ascertain  whether  genuine  pellagra  exists  in  the  South, 
and  whether  the  remedies  employed  are  properly  applied. 

My  limited  opportunities  for  studying  the  malady  prevent  my 
giving  you  any  satisfactory  conclusions  on  this  point,  much  as  I 
should  like  to  throw  some  light  on  the  question.  My  paper  will 
be  limited  to  the  report  of  four  cases  in  children. 

PATIENT  ELLEN  BOON,  born  in  Chesterfield  County,  where 
she  lived  until  seven  years  old,  then  moved  to  Lancaster,  where  her 
people  worked  in  a  cotton  mill  for  three  years.  Afterwards  the 
family  moved  on  a  farm  where  they  lived  for  two  years.  They  then 
moved  back  to  the  mill  and  lived  a  year,  going  thence  to  a  cotton 
mill  at  Camden  and  there  remaining  five  months.  From  Camden 
they  moved  to  Rock  Hill. 

Family  History. 

Father  and  mother  both  living.  The  patient  has  two  brothers  and 
three  sisters  living.  There  have  been  no  deaths  in  the  family.  I 
found  no  history  of  consumption,  cancer  or  rheumatism  in  family. 

Personal  History. 

Patient  has  had  mumps,  whooping  cough  and  measles.  Her 
bowels  have  been  loose  most  of  her  life;  otherwise  fairly  healthy. 
I  am  unable  to  find  out  what  quality  of  food  the  patient  has  had, 
but  now  she  seems  to  have  an  abundant  supply  of  fairly  nutritious 
food. 

Present  Illness. 

The  patient  noticed  a  red  rash  on  the  back  of  her  hands  in  April 
while  living  in  Camden  and  thought  it  sunburn.  The  rash  disap- 
peared in  forty  days,  but  in  July  this  red  surface  began  to  crust  and 
peel  off,  the  patient's  bowels  became  worse  and  she  grew  very  weak 
and  nervous.  Her  mouth  was  never  sore.  Her  tongue  was  moist 
and  red  and  the  papillae  were  enlarged.     Patient  uses  snuff. 


268 

Examination. 

Patient's  height  is  5  feet,  weight  55  pounds.  She  is  very  anemic 
and  thin.  Her  skin  was  rough  and  peeled  off  on  the  back  of  hands, 
on  arms,  shoulders,  forehead  and  back  of  neck,  front  of  chest,  thighs, 
knees  and  instep  of  foot.  The  patient's  hair  is  falling  out.  The 
papillae  of  her  tongue  are  enlarged  and  pigmented,  and  her  knee 
jerk  is  very  much  exaggerated.  The  patient  moves  about  very 
slowly  and  before  treatment  was  begun  she  was  unable  to  get  out  of 
bed.  She  was  very  nervous.  She  answered  questions  in  a  slow, 
indistinct  tone.  Pupils  react  to  light,  and  there  is  nothing  abnormal 
about  the  heart  or  lungs.  No  examination  of  stool  or  blood  has 
been  made. 

JOHN  MOORE,  three  years  and  five  months  of  age,  born  and 
lived  at  the  house  where  he  died.  The  house  is  surrounded  by  a 
farm  and  there  are  only  two  houses  within  half  a  mile  of  the  place. 
His  sisters  and  mother  work  in  a  cotton  mill. 

Family  History. 

Father   and   mother   still   living.     The    father   is   worthless    and 
deserted  the  family  some  time  ago.     I  don't  know  how  his  health 
is  now.    The  mother  is  very  stout  and  healthy.    The  patient  has  three ' 
sisters  living,  and  they  are  strong  and  healthy,  with  excellent  com- 
plexions.   He  had  no  brothers. 

Personal  History. 

The  child  was  well  grown  to  his  age,  looked  perfectly  healthy 
and  was  very  ruddy.  So  far  as  I  could  see  he  had  an  abundance  of 
nutritious  food  and  good  sleeping  quarters.  He  was  very  fond  of 
corn  bread  and  buttermilk.  Had  an  attack  of  whooping  cough  last 
winter,  for  which  I  treated  him.  Had  a  few  attacks  with  bowels 
while  teething.  I  treated  the  child  in  June  for  what  I  thought  to 
be  malaria,  at  which  time  I  overlooked  the  condition  of  his  hands. 
This  is  all  the  sickness  the  child  ever  had  until  the  attack  from  which 
it  died.  Present  illness  commenced  in  May  with  a  red  rash  on  back 
of  hand  and  dorsal  surfaces  of  feet.  The  mother  thought  this  was 
caused  by  a  scouring  soap  which  the  child  had  been  accustomed  to 
bathe  its  feet  and  hands  with.  The  redness  soon  faded  and  the 
child  had  no  further  symptoms,  save  occasionally  loose  bov/els.  On 
September  12th  I  was  called  to  see  the  child,  when  I  found  a  dark 
desquamating  crust  on  the  dorsal  surfaces  of  feet  and  hands,  and  on 
nose  and  back  of  neck.     The  child  was  very  nerv^ous  and  demented. 


269 

It  could  hardly  be  kept  in  bed.  September  13th  I  was  unable  to  get 
to  the  child,  as  I  was  quite  busy,  but  was  sent  for  several  times  on 
account  of  the  restless  condition  of  the  child.  The  knee  jerk  was 
very  much  exaggerated,  mouth  was  very  sore  and  the  papillae  on 
tongue  were  enlarged.  On  September  12th,  the  child's  bowels  were 
very  loose  with  a  good  deal  of  mucus  in  the  stools.  On  September 
14th  the  stools  had  become  bloody  and  increased  in  number  and  the 
child  became  maniacal.  On  September  15th  the  stools  were  almost 
entirely  blood  and  the  child  was  no  longer  able  to  get  up  from  the 
bed.  I  took  sick  this  day  and  was  unable  to  see  the  child  any  more 
and  turned  it  over  to  a  young  practitioner  who  watched  it  until  it 
died  on  September  i8th.  I  have  been  unable  to  get  any  definite 
information  from  this  young  man. 

BERTHA  AND  GRADY  NEAL,  white,  age  7  and  6  years 
respectively,  were  born  in  Rock  Hill  and  lived  here  except  about 
three  years  when  they  moved  to  Chester  and  from  there  to  Union 
and  then  to  Yorkville,  then  back  to  Rock  Hill.  They  have  always 
lived  about  cotton  mills  and  have  been  pretty  good  livers  for  mill 
people. 

Family  History. 

Mother  and  father  both  living.  Father's  health  good ;  mother  has 
pellagra  also.  They  have  one  brother  one  year  and  four  months 
old,  who  has  had  a  sore  mouth  and  loose  bowels.  They  have  had 
no  deaths  in  the  family.  The  family  is  not  of  a  nervous  tempera- 
ment, and  they  keep  an  exceptionally  clean  house.  There  is  no 
consumption,  cancer  or  rheumatism  in  the  family. 

Personal  History. 

Bertha  has  had  measles,  whooping  cough  and  mumps.  She  has 
had  loose  bowels  most  of  her  life  and  has  a  marked  kyphosis.  She 
is  fairly  well  nourished  and  not  extremely  ansemic.  Grady  has  had 
mumps  and  whooping  cough  and  this  last  spring.  He  is  rosy  and 
extremely  healthy  looking.  He  had  the  dermititis  last  spring,  which 
disappeared  during  the  fall,  but  was  never  noticed  by  a  physician. 

Present  Illness. 

I  treated  these  children  and  mother  most  of  the  spring  and  summer 
for  severe  diarrhoea  and  stomatitis  without  once  thinking  of  pellagra. 
Nearly  everybody  else  at  the  same  village  was  suffering  with  same 
complaint.  This  ran  on  with  severe  exacerbations  at  times  until 
August,  the  girl  and  boy  both  developed  a  severe  dermititis  on  the 


270 

feet,  hands  and  necks.  Then  my  eyes  were  opened.  They  are 
much  improved  now  but  their  bowels  are  still  loose.  Their  mouths 
are  still  sore  and  the  papillae  are  enlarged  but  not  pigmented.  The 
mother  did  not  have  dermititis,  but  there  was  a  distinct  bronzing  of 
skin  when  exposed  to  sunlight.  Bertha  has  been  extremely  nervous 
and  showed  some  signs  of  dementia.  Grady,  the  boy,  never  showed 
any  nervous  symptoms.  Both  suffered  from  severe  gastritis  with 
nausea  and  vomiting  on  appearance  of  the  dermititis. 

Examination. 

Both  have  a  rusty  appearance  of  skin  on  hands  and  feet,  also  on 
back  of  neck,  which  comes  off  in  large  crusts.  Bertha  for  awhile  was 
scarcely  able  to  get  about  and  hardly  gave  an  intelligent  answer  to 
questions.  Bertha  has  increased  knee  jerk,  the  tongues  of  both  are 
red  and  moist  and  papillae  are  very  distinct. 


271 


A  CASE  OF  LABOR  IN  A  PELLAGRIN,   WITH   SUBSE- 
QUENT HISTORY  OF  MOTHER  AND  CHILD 

CROWN  TORRENCE,   M.  D. 

UNIONj    S.    C. 

As  a  part  of  the  report  in  this  case  of  labor  in  a  pellagrin,  it 
seems  advisable  to  preface  my  remarks  with  a  brief  history  of  the 
mother  previous  to  the  accouchement.  White,  native  of  South 
Carolina,  in  good  financial  circumstances,  was  42  years  of  age  at  the 
time  of  confinement  and  had  borne  nine  children,  the  youngest  being 
then  five  years  of  age.  Of  these  nine  children  four  were  living  and 
in  splendid  health,  while  five  had  died  during  the  first  two  years  of 
their  lives,  one  from  diphtheria,  one  from  convulsions,  and  the  other 
three  from  cholera  infantum.  She  was  married  at  19  years  of  age ; 
all  of  her  confinements  being  normal,  and  the  first  occurring  in  her 
20th  year.  The  menstrual  discharges  had  been  regular,  but  with 
a  tendency  to  be  too  free  and  exhausting.  Two  years  before  the 
birth  of  the  child  in  this  report  she  developed  a  serous  diarrhoea 
which  attended  her  through  the  summer  despite  treatment.  No 
other  symptoms  were  noticed  until  the  following  summer,  when 
there  was  a  return  of  the  diarrhoea,  some  digestive  disturbances, 
much  lassitude  and  a  decrease  in  body  weight.  No  regular  medical 
service  was  had  except  as  some  pronounced  exacerbation  of  these 
symptoms  would  occur.  In  November  of  this  year,  1907,  she  missed 
her  regular  menstruation,  and  on  account  of  her  weakened  condi- 
tion she  felt  relieved  over  this,  not  atrributing  it  to  pregnancy,  but 
to  some  beneficent  oversight  of  nature.  In  December,  though,  she 
became  satisfied  that  she  was  pregnant,  and  from  then  until  her  con- 
finement, the  13th  of  July,  1908,  her  condition  to  her  became  an 
obsession.  The  first  five  months  of  her  pregnancy  during  the  win- 
ter months  were  attended  by  much  nausea,  digestive  disturbances, 
insomnia  and  great  mental  apprehension.  The  buccal  mucous  mem- 
brane during  this  stage  had  a  raw  and  inflamed  appearance,  while 
the  tongue  seemed  denuded  of  epithelium.  During  the  last  four 
months  the  nausea  and  stomachic  disturbances  were  greatly  abated, 
and  the  patient  was  hungry,  but,  because  of  a  return  of  the  serous 
diarrhoea,  was  in  much  fear  of  all  food,  and  could  hardly  be  induced 
to  take  any  nourishment.    At  times  this  diarrhoea  seemed  to  almost 


threaten  the  onset  of  premature  labor;  but  at  no  time  during  the 
most  severe  spells  of  diarrhoea  was  any  rise  of  temperature  noted. 
The  insomnia  grew  worse  and  the  mental  condition  became  pitiful; 
the  daily  cry  was,  "\  would  rather  be  dead,  I  know  I  am  going  to 
die."  Opiates  alone  gave  any  temporary  comfort,  and  because  of  an 
idiosyncrasy,  the  after-effects  were  worse  than  the  original  condi- 
tion. Albuminurea,  with  swollen,  bloated  face,  and  dropsical  swell- 
ings in  the  feet,  legs,  thighs  and  up  to  mid-waist,  appeared  at  end 
of  fifth  month,  and  continued  until  delivery,  despite  treatment. 

No  erythema  was  noticed,  although  the  patient  complained  of  the 
skin  over  the  feet  and  ankles  being  on  fire.  This  was  passed  over 
as  being  due  to  the  oedema.  The  patient  was  confined  to  her  room 
during  the  entire  time  of  this  pregnancy,  and  this  may  have  some 
bearing  on  the  non-appearance  of  any  erythema.  She  was  delivered 
on  the  night  of  the  13th  of  July,  1908,  of  a  full  sized  girl  baby.  The 
labor  was  much  easier  than  was  expected,  the  placenta  coming  away 
clean,  and  the  womb  contracting  down  hard,  without  any  manipula- 
tion. When  the  placenta  came  away  a  teaspoonful  of  F.  E.  Ergot 
with  I. -40  grain  strychnine  was  given  by  the  mouth,  simply  as  a 
routine.  The  trained  nurse  I  had  secured  for  the  occasion  felicited 
with  me  over  the  result,  the  outcome  of  which  we  had  been  antici- 
pating in  such  great  dread. 

After  the  toilets  of  the  mother  and  child  had  been  made  and  I 
had  finished  drying  off  my  instruments  (which  I  fortunately  had 
not  needed),  and  had  eaten  a  little  luncheon  in  an  adjoining  room, 
and  was  ready  to  leave  the  house,  in  all  about  one  and  one-half 
hours  after  the  placental  membranes  were  delivered,  I  was  hastily 
called  by  the  nurse  to  the  m.other's  bedside.  The  patient  had  just 
vomited  the  Ergot  and  she  was  ghastly  pale,  yawning  and  gasping 
for  breath.  Underneath  the  bed  a  little  stream  of  blood  was  begin- 
ning to  trickle  to  the  floor.  Fortunately  a  fountain  syringe  which 
we  had  neglected  to  take  down  was  suspended  by  the  head  of  the 
bed.  Quickly  emptying  this  of  its  half  tepid  water  and  filling  with 
water  from  a  kettle  that  was  nearly  boiling,  and  assisted  by  a  colored 
servant,  I  inserted  the  nozzle  up  into  the  womb,  holding  it  there 
with  one  hand  and  with  the  other  hand  kneading  and  squeezing  the 
abdomen  with  all  the  strength  of  desperation.  The  nurse  in  the 
meantime  had  been  ordered  to  secure  Ergotole  from  my  bag,  and  to 
use  hypodermically.  In  all  I  think  she  used  five  hypodermics  as  fast 
as  she  could  fill  the  syringe  and  inject.  At  first  I  could  feel  no 
uterus   under   the   abdominal   wall.     Everything  was   relaxed   and 


273 

flabby,  as  so  much  soft  flesh.  After  a  few  minutes,  which  to  us 
were  interminable  hours,  I  felt  the  contractions  start;  and  in  a 
quarter  of  an  hour  the  womb  was  back  again,  hard  and  firm  as  a 
croquet  ball.  There  was  no  return  of  the  hemorrhage,  the  lochia 
being  about  natural  and  continuing  about  14  days.  We  injected 
some  normal  salt  solution  per  rectum,  but  as  to  how  much  was 
retained  or  the  beneficial  effect  derived,  I  was  never  able  to  say. 
There  was  never  any  rise  of  temperature.  The  dropsical  condition 
disappeared,  as  did  the  diarrhoea  and  digestive  disturbances. 

The  patient  had  seemed  anaemic  before  labor,  but  now  she  looked 
as  if  there  could  not  be  a  drop  of  blood  in  her  body.  There  was  no 
lactation.  Outside  of  anaemia,  non-lactation  and  extreme  exhaus- 
tion, the  patient  made  a  comparatively  uneventful  slow  recovery. 
She  was  not  able  to  walk  around  in  the  house  until  nearly  three 
months  after  labor.  She  passed  through  the  winter  of  iqoS-'oq  in 
fairly  good  health,  so  far  as  comfort  was  concerned,  but  with  the 
advent  of  spring,  1909,  she  again  developed  the  diarrhoea  and  all  the 
whole  train  of  nervous  symptoms,  insomnia,  loss  of  appetite,  vertigo, 
raw  mouth  and  tongue,  and  she  was  forced  to  take  to  her  bed. 
It  was  just  at  this  time  that  a  positive  diagnoses  of  pellagra  was  made. 
The  patient  had  gone  out  into  her  vegetable  garden  and  sat  in  the 
sun  watching  the  weeding  of  some  of  her  plants ;  becoming  faint  she 
was  assisted  back  to  the  house,  and  after  resting  had  a  lunch  of 
warm  corn  muffin  bread  and  butter,  of  which  she  was  very  fond  and 
accustomed  to  eat  regularly.  In  a  short  time  she  became  very  ill, 
exclaiming,  "That  muffin  has  made  me  sick,  I  never  want  to  taste 
any  again."  Then  looking  at  her  hands  she  called  attention  to  them, 
saying,  "And  here  I  have  gotten  my  hands  all  sun-burned  out  in  the 
garden  today  also."  These  incidents  were  related  to  me  in  the  same 
afternoon  when  I  was  called  in ;  and  it  was  then  that  I  first  allowed 
myself  to  realize  that  it  was  a  case  of  pellagra.  This  was  the  first 
appearance,  to  my  knowledge  or  to  her  memory,  of  any  erythema 
or  sun-burn. 

The  diarrhoea,  at  first  serous  in  character,  became  sanguinolent, 
and  so  continued  for  over  a  month,  then  became  serous  again.  The 
use  of  large  quantities  of  the  bromides  were  necessary  to  get  even 
three  or  four  hours  sleep  in  the  twenty-four.  The  erythema  was 
marked  and  uniform  over  the  dorsal  aspect  of  each  hand,  and  from 
over  the  elbow  down  the  ulnar  surface  of  the  fore-arm.  Pustules 
appeared  upon  the  face,  and  several  good-sized  boils  came  upon  the 
hands  and  fingers.  The  feet  were  again  on  fire  and  required  con- 
is— p.  c. 


274 

stant  hot  salt  baths,  and  even  carbolized  ointments  were  needed  to 
give  temporary  respite. 

The  patient  seemed  to  brood  over  the  fact  that  she  was  going 
crazy,  and  would  continually  say  to  me  that  she  must  be  losing  her 
mind.  She  developed  a  morbid  antipathy  toward  her  child,  not 
wishing  to  see  it  or  have  it  where  she  could  hear  it,  attributing  to 
the  child  her  lamentable  condition. 

She  was  placed  on  Donovan's  solution  about  the  last  of  May,  1909, 
and  maintained  a  dosage  of  five  drops  three  times  a  day  until  the 
middle  of  October  before  any  puffiness  appeared  under  the  eyelids ; 
as  this  puffiness  apeared  the  dosage  was  decreased  to  2  drops  three 
times  a  day,  until  it  disappeared,  then  increased  to  a  three-drop  dos- 
age three  times  a  day,  which  is  now  her  only  medicament.  She  was 
confined  to  her  bed  from  May  until  the  last  of  July,  since  which 
time  she  has  gradually  improved  in  every  way.  She  has  gained  10 
pounds  over  her  April  weight,  her  color  is  fairly  good,  and  it  takes 
close  observation  to  detect  the  scar  cuff  around  each  wrist.  The 
erythema  in  this  case  was  dry  and  scaly,  and  under  advice  from  Dr. 
Babcock,  who  saw  this  case  with  me,  three  applications  of  tincture 
of  iodine  removed  all  the  scales  and  left  a  soft  smooth  skin. 

I  wish  to  call  attention  to  the  fact  that  this  patient  menstruated 
slightly  six  weeks  after  the  birth  of  her  child,  and  has  been  regular 
each  month  since.  The  discharges  are  not  free  and  are  very  black 
and  last  only  two  or  three  days.  She  now  sleeps  from  five  to  six 
hours  each  night,  and  attends  to  much  of  her  house  work,  but  has 
trouble  sewing  on  account  of  her  eyes,  which  she  says  have  failed 
very  noticeably.  She  is  still  easily  upset,  and  is  extremely  careful 
with  her  diet,  which  is  chiefly  eggs  and  sweet-milk.  By-the-way,  she 
says  that  a  number  of  the  breakfast  foods  and  cereals  will  upset  her 
bowels  and  make  her  feel  almost  like  the  muffin  did. 

Now  a  few  words  as  to  the  child :  It  was  brought  up  on  the  bot- 
tle, and,  though-  for  the  first  year  it  was  simply  a  scrawny  little 
assortment  of  bones  covered  with  skin,  it  all  at  once  took  on  a  notion 
to  live,  and  became  fat  and  is  now  a  very  well  nourished  i6-months- 
old  girl  with  four  teeth  and  a  lusty  yell.  When  about  8  months  old  it 
had  some  20  boils  and  furuncles  to  appear  at  different  times  and 
places  about  over  the  body.  Since  then,  nothing  has  disturbed  her 
growth,  except  the  pitiful  fact  that  she  has  spina  bifida,  and  the 
lower  extremities  from  the  hips  down  are  poorly  developed. 


275 


DISEASES  OF  THE  EYE  IN  PELLAGRA 

A,  B.    CLARKE^   M.   D. 

PLANTERSVILLE,    S.    C. 

In  diseases  of  the  eye  in  pellagra  I  find  no  difference  in  the  symp- 
tomatology, characteristic  appearance  nor  complications,  save  only 
they  are  very  prone  to  exhibit  the  same  cycle,  as  it  were,  a  recrudes- 
cence in  early  spring-time  and  as  summer  progresses  make  recovery. 
My  observations  and  findings  have  primarily  been  upon  the  rice  field 
negro,  who  has  been  inured  to  hardship,  poorly  educated  and  equally 
poorly  nourished,  seldom  able  to  read,  and  when  he  has  disturbances 
attributes  it  to  local  conditions.  My  patients  have  invariably  given 
history  of  damp  meal,  grits  in  lumps  in  bags,  which  have  been  wet 
carrying  home  in  cotton  sacks,  openly  exposed  to  vermin  and  dew, 
many  times  sour  and  eating  sour  corn  bread.  My  attention  was  first 
directed  to  this  disease  in  1906.  The  patients  gave  me  history  of 
rheumatic  pains,  generally  malaise,  sensation  of  heat  esophagus  and 
in  the  region  of  the  kidneys,  radiating  to  the  hands  and  feet,  notice- 
ably the  palms  and  soles.  (One  child  had  spastic  paralysis.)  All 
complain  of  vertigo,  neuralgic  pains  in  the  posterior  aspect  of  neck. 
The  dorsum  of  their  hands  and  feet  they  said  were  "sun-burnt,"  skin 
swollen  tense,  burn  and  itch,  severe  stomatitis  petallar  reflexes  exag- 
gerated; insomnia,  anorexia  and  erythema  with  petchiae  occurring 
at  times.  Also  small  oval  blisters,  even  bullae,  which,  upon  breaking 
down,  leave  indolent  ulcers.  The  chief  physical  symptoms  delusions, 
apathy,  melancholia  disorientation  with  symptoms  of  dementia 
prsecox.  In  two  of  my  cases  between  the  fingers  cracked,  extending 
to  metacarpal  bones  and  exposing  ligaments.  The  tongue  and  mouth 
red  inflamed  and  sore,  gums  swollen  at  times  and  present  appearance 
of  salivation.  Lips  swell,  and  they  appear  almost  scarlet,  crack  and 
become  denuded.  The  tongue  has  presented  three  varieties  to  me, 
heavily  coated  with  brown  streaks  in  centre,  notched  around  the 
edges  and  very  red.  Again,  smooth  and  denuded  of  epithelium,  and 
in  another  instance  sleek  with  deep  fissures.  Have  never  seen  any 
changes  in  the  hair  and  nails  of  my  patients.  All  give  digestive 
disturbances  and  lack  of  appetite.  As  the  disease  progresses  the 
mental  disturbances  increase  from  extreme  dull  apathetic  conditions, 
slow  in  speech,  listless,  tired  and  ennui,  melancholy  and  dreads  of 


276 

persecution,  even  suicidal  tendencies  have  been  exhibited.  Some  of 
these  patients  have  informed  me  these  conditions  have  crept  upon 
them  insidiously,  gradually  becoming  more  severe  each  spring  and 
summer.  (Three  of  these  patients  have  since  died.)  Many  of  them 
complain  of  pains  in  the  eyes,  one  of  diplopia,  and  others  of  various 
symptoms.  I  examined  more  carefully  and  present  the  following 
data :  ( i )  Man,  42,  negro.  Had  been  working  timber  and  living 
upon  a  diet  of  grits  and  corn  meal  mush,  crackers  and  cheese.  All 
of  which  he  stated  had  become  moulded  and  soured,  as  he  had  no 
place  save  a  sack  to  keep  it  in.  He  was  suffering  from  ectropion, 
both  eyes  with  slight  conjunctivitis.  Had  marked  pellagra  symp- 
toms. Iris  was  dilated.  Very  little  photophobia-corns  aqueous,  lens 
clear,  vitreous,  slightly  hazy;  choroid  showing  evidence  of  atrophy. 
Dark  pigmented  areas,  the  nerve  head  was  oval,  suggesting  myopic 
conditions.  Arteries  pale,  veins  thick  and  heavy.  The  other  eye 
was  normal,  consensual  reaction  from  left  to  right,  but  not  from 
right  to  left.  I  made  several  further  attempts  for  examinations,  but 
patient  was  in  a  cachectic  condition  and  refused,  dying  in  seven  days 
after  the  last  attempt  to  view  fundas.  (2)  Child,  6^,  boy,  negro, 
epiphora  both  eyes,  marked  pellagra  patient;  talked  incoherently  all 
the  time;  had  3-5  degree  fever  (axilla).  History  positive,  mouth, 
tongue  and  nares  raw.  Mother  stated  child's  eyes  became  sore  every 
spring,  which  suggested  vernal  catarrh.  Examined  for  it,  but  was 
not  present.  Had  marked  conjunctivitis  with  small  granulation, 
which  resisted  all  treatment.  Cornse  aqueous  lens  vitreous  clear. 
Opthalmoscopic  findings :  Fundus  dark  black  spots  similar  to 
retinitis  pigmentosa,  only  limited  to  about  four  M.  M.  around  nerve 
head  and  involving  macula  regions.  There  was  no  evidence  of 
choroditis,  nor  were  these  dark  areas  in  any  other  part  of  fundis. 
Mother  stated  child's  eyes  had  been  sore  in  springtime  for  three  or 
four  years,  when  his  hands  and  feet  became  "sun-burnt."  His 
vision  had  become  worse  this  time.  (From  this  child  I  recovered 
uncinarias)  upon  two  occasions.  Child's  hands,  feet,  arms  and  legs 
and  nape  of  neck  in  horrible  condition,  extremely  emaciated.  Died 
five  days  after  my  seeing  him.  They  refused  post-mortem,  nor 
would  they  allow  me  to  remove  one  of  the  eyes.  (3)  Man,  38,  negro. 
History:  Working  in  swamp  making  shingles,  living  on  grits  and 
condensed  milk.  He  termed  it  "stir-mush."  Would  make  enough  at 
night  to  do  next  day.  Sometimes  it  would  sour  in  the  pots,  he  said, 
but  if  boiled  over  it  was  fit  to  use.  It  had  given  him  indigestion,  he 
stated.    Both  hands,  arms  and  legs  presented  distinct  line  of  demar- 


cation  with  round  ulcers,  some  confluent  irregular  edges,  and  edema. 
Patient  was  painfully  emaciated ;  complained  of  pains  in  the  eyes, 
with  burning  sensation  and  failing  vision.  Upon  examination  I 
found  fundus  visible  and  appeared  normal,  optic  nerve  palfe,  almost 
white,  beginning  nerve  atrophy.  Patient  was  to  return  in  fourteen 
days;  was  unable  to  do  so,  dying  in  nineteen  days  after  last  visit. 
(4)  Girl,  17,  negress.  Anemic  enlarged  glands,  cervical  and  epitroch- 
lear  for  three  years;  hands  and  feet,  arms  and  legs  had  become  de- 
nuded. Was  now  raw  with  fetid  ulcers  on  one  leg  almost  to  knee. 
Right  eye  cornea  hazy  with  small  ulcers,  iris  irregularly  dilated  pos- 
terior synechia,  aqueous  hazy,  vitreous  muddy,  fundal  lesion  large 
hemorrhage  to  temporal  side.  Patient  stated  she  was  not  aware  that 
she  was  blind  in  that  eye.  •  Had  floating  bodies ;  was  unable  to  get 
any  detail  of  fundus.  Left  eye  normal.  In  inner  canthus  of  both 
eyes  small  papilla,  which  exudea  watery  substance  upon  being  punc- 
tured. Patient  came  regularly  for  four  weeks,  becoming  rapidly 
worse;  excessive  diarrhose  and  became  almost  unmanageable,  refus- 
ing to  eat.  Died  in  eleven  days  after  last  visit.  (5)  Woman,  42, 
negress.  Second  year  had  sun-burnt  hands  with  sore  mouth,  vertigo ; 
had  lost  considerable  flesh,  had  grown  melancholy  with  hallucinations. 
Iritis  in  right  eye  three  weeks ;  history  of  damp  grits ;  bought  them 
because  they  were  cheap ;  damaged  meal.  Upon  examination,  hands 
and  feet  desquamating  in  layers,  shelling  off,  leaving  shiny  tense 
beneath,  and  in  places  raw,  bleeding  surface.  Lips  and  tongue  de- 
nude. Suffered  from  insomnia  and  had  no  memory.  Opthalmoscape 
gave  no  fundal  lesions.  Patient  recovering.  (6).  Woman,  26, 
negress.  First  year  mouth  became  sore  and  denuded,  bright  red  in 
appearance,  distinct  erythema;  complained  of  pains  in  the  eyes, 
smarting  and  burning.  Patient  came  every  other  day  for  two  weeks, 
and  each  morning  had  a  film  of  blueish  tint,  oval  cornea  of  both 
eyes.  At  end  of  six  weeks  she  stated  that  eyes  gave  her  no  further 
trouble.  Physical  condition  improved.  Mentally  slowly  making 
progress.  Opthal  moscopic  shows  nerve  head  normal,  arteries  very 
small,  veins  enlarged;  one  small  black  area  between  macula  and 
nerve  head  of  left  eye.  Right  eye  arteries  very  small,  veins  enlarged ; 
small  hemorrhage  in  vein  to  nasal  size  in  physilogical  cup.  This 
patient  gives  positive  history  when  and  where  she  obtained  the  dam- 
aged meal. 

In  presenting  these  histories  I  have  refrained  from  repetition  as 
much  as  possible,  also  from  citing  pellagra  symptoms.  The  class  of 
persons  I  find  who  are  suffering  are  they  who  lack  nitrogenous  food. 


278 

Many  exist  upon  rice,  grits  and  potatoes  and  a  little  cheap,  poor 
grade  pork,  termed  second  or  butts.  They  need  meat,  red  meat,  and 
a  variety  of  vegetables.  In  four  out  of  seven  cases  I  examined,  I 
found  uncinaria,  in  all  anemia,  the  treatment  has  been  supportias  and 
nutritious.  Tonics  increasing  Tr.  CI.  Fe.  to  30  m.,  Tid.  and  Fowlers' 
Sal.  to  24  m.  Tid.  Cod  liver  oil,  eggs,  bevinine  and  pepto  manganse 
(Gudo's)  acetate  of  lead  and  opium  for  diarrhoea.  Phosphoric  acid 
and  fish  diet,  also  oatmeal.  Strychnine,  tr.  nux  vomica;  milk  in 
abundance.    I  find  local  applications  of  practically  no  value. 

These  cases  are  irom  the  extreme  rural  districts ;  hygienic  condi- 
tions are  very  poor.  Mentally,  from  educational  standpoint  nil,  not 
one  gave  luetic  history,  all  gave  malaria.  In  one  family,  mother  had 
chronic  condition,  son  acute;  both  died.  I  have  been  informed  that 
many  negroes  bought  damaged  meal  which  had  been  recovered  from 
a  flat,  it  having  sunk.  Some  of  the  negroes  became  sick,  had  vertigo, 
abdominal  pains  and  intense  gastric  disturbances. 

From  my  observation  I  am  of  the  opinion  that  pellagra  is  a  trophic 
neurotic  condition,  involving  the  entire  sympathetic  system,  not  an 
autointoxication,  but  secondary  to  the  ingestion  of  a  fungi  or  fer- 
ment which  causes  katabolic  metamorphosis. 


279 


EYE  SMYPTOMS  OF  PELLAGRA 

E.   M.  W HALEY,  M.  D. 

COLUMBIA^    S.    C. 

Gentlemen :  The  results  reported  were  compiled  from  the  exam- 
ination of  thirty-five  pellagrins,  and  50  per  cent,  of  these  were 
insane,  thus  we  would  expect  to  find  the  nervous  elements  much  in 
evidence.  The  examination  as  to  field  and  color  it  was  impossible 
to  get.  It  is  rather  disappointing  that  I  cannot  make  out  but  one 
symptom  that  seems  to  be  characteristic  of  this  disease,  and  on 
account  of  the  small  number  of  cases,  would  not  like  to  be  too  san- 
guine as  to  its  being  pathognomonic  of  pellagra.  Still,  Lombroso 
seemed  to  find  it,  though  he  did  not  state  to  what  extent.  This 
symptom  appears  as  if  the  retinae  were  thickened  and  gives  the  fun- 
dus reflex  a  peculiar  indistinct  yellowish  color,  and  is  not  so  pro- 
nounced as  the  senile  reflex. 

The  skin  lesion  occurs  on  the  eyelids,  both  upper  and  lower,  more 
especially  the  lower ;  is  well  marked,  and  line  of  demarkation  positive 
and  definite,  appearing  like  an  echemosis  of  traumatic  origin,  but  is 
not  smooth  on  the  surface.    Two  cases. 

The  dilitation  of  the  pupil  was  not  so  prevalent  as  we  expected 
to  find  from  the  reports  of  our  Italian  friends.  This  may  be  ac- 
counted for  by  the  fact  that  observations  in  different  localities  make 
some  variation  in  the  symptoms,  and  the  season  has  also  been  seen  to 
affect  the  kind  and  virulence  of  the  attack. 

As  stated,  the  number  of  cases  examined  was  thirty-five,  their  ages 
varying  from  eight  to  seventy-six  years,  only  two  of  whom  showed 
normal  eyes. 

The  appearance  of  the  patients  was  that  they  did  not  Carry  their 
upper  lids  as  high  as  they  should,  thereby  giving  the  appearance  of 
general  lassitude.  This  dyskinesis  of  the  upper  lids  in  these  subjects 
is  not  due  to  paralysis ;  it  is  voluntary  and  due  to  the  fear  of  light. 
If  unilateral  and  real,  care  must  be  taken  with  the  examination  to 
exclude  paresis  from  other  cause.  Ptosis,  due  to  ptomaine  poisoning, 
fungi,  lead,  etc.,  must  be  eliminated. 

Congenital  ptosis  will  be  confusing  unless  we  bear  in  mind  that  it 
is  permanent,  usually  bilateral,  and  often  incomplete. 

If  you  can  make  the  pallagrin  look  up  he  will  not  correct  the  lid- 


28o 

drop  by  throwing  the  head  back,  unless  there  be  other  cause  present 
and  an  involuntary  ptosis  exist. 

Frequently  on  raising  the  patient's  head  the  lid  or  lids,  as  the  case 
may  be,  will  descend  lower. 

All  pellagrins  are  unresponsive,  and  no  field  examination  could  be 
made.  With  few  exceptions,  the  examination  had  to  be  made  while 
the  patient  was  in  bed.  The  dilated  pupil  occurred  bilaterally  in 
three  cases  only;  unilaterally  in  two  cases,  and  one  of  the  bilateral 
cases  was  myopic.  Two  cases  resisted  the  action  of  homatropine  for 
two  hours,  four  resisted  it  less  strenuously,  while  the  others  reacted 
in  the  usual  twenty  minutes.  Hypersensitiveness  to  light  with  con- 
tracted pupils  was  the  rule.  (This  contraction  was  not  meant  to 
indicate  that  they  were  pin-point  pupils,  but  were  smaller  than  nor- 
mal.) 

Shallow  anterior  chambers  were  found  in  33  per  cent,  of  the  cases. 
Strabismus  could  not  be  detected  when  there  was  no  other  evident 
cause. 

Where  the  gastro-intestinal  symptoms  were  very  pronounced  and 
the  inflammation  extends  to  the  mouth  and  post-nasal  space,  we  find 
an  obstruction  of  the  lachrymal  duct  due  to  continuity  of  surface. 
This  was  noted  in  five  cases,  all  of  which  had  the  mucous  membranes 
very  much  affected  by  the  disease.  Photophobia  of  slight  degree, 
without  the  inflammatory  changes  which  usually  accompany  this  con- 
dition, was  present  in  six  cases. 

The  findings,  as  tabulated,  are  as  follows : 

Lids — Paretic,  i ;  lachrymation,  2 ;  dachryocistitis,  2 ;  conjuncti- 
vitis, 2;  muddy  conjunctivae,  2;  jaundiced  conjunctivae,  3 ;  obstruc- 
tion of  lachrymal  duct,  5. 

Corneal  Abnormalities — Ulcer,  4;  superficial  inflammation,  2;  in- 
creased sensibility,  2 ;  subnormal  sensibility,  7. 

Muscles — Paresis  (Rt.  rectus),  i ;  mystagmus,  i. 

Anterior  Chamber — Shallow,  12;  deep,  i. 

Iris — Iritis  serous,  i ;  sluggish  reaction  to  light,  6 ;  hypersensitive, 
4 ;  photophobia,  6 ;  reaction  to  homatropine,  slow,  4 ;  prompt,  i ; 
spastic  reaction  to  light,  2. 

Pupils — Unilaterally  dilated,  2;  bilaterally  contracted,  3;  bilat- 
erally dilated,  3  ;  Argyle  Robertson,  i. 

Tension — Plus  bilateral,  i;  plus  unilateral  (O.  S.),  2. 

Fundus — Retinitis,  2 ;  detached  retina,  i ;  optic  atrophy,  3 ;  optic 
neuritis,  3. 


28l 

Lens — Cataract  bilateral,  3;  unilateral,  2;  cloudy  lens,  i. 

Arteriosclerosis,  15. 

After  examining  somewhat  over  half  of  these  cases  I  found  that 
there  was  most  common  a  dilation  of  the  retinal  veins  and  a  some- 
what yellowish  reflex  from  the  retina  that  I  do  not  remem.ber  seeing 
elsewhere.  This  appearance  is  hard  to  describe,  appearing  as  a 
thickening  of  the  retina  itself. 

The  arteriosclerosis  which  appears  in  so  many  of  the  cases  is  of. 
every  stage  and  occurs  in  the  young  as  well  as  the  older. 

Five  additional  cases  examined  gave  the  following : 

No.  I.  L.  B. ;  bilateral  ptyrigiums,  pupils  quick  and  contracted, 
arcus  senilis;  no  inequality.  Rt.,  reacted  less  promptly  to  homatro- 
pine.    Optic  neuritis ;  veins  as  usual. 

No.  2.  L.  M. ;  corneal  sensation  subnormal;  anterior  chamber 
shallow ;  retinitis  O.  S. 

No.  3.  Dr.  P. ;  corneal  ulcer  left  eye. 

No.  4.  R.  A. ;  sensitive  to  light,  muddy  conjunctivae  O.  D. ;  iris 
slow  to  homatropine. 

Opaque  nerve-fibres,  O.  S.,  temporal  side. 

Veins ;  atony. 

No.  5.  D.  S.,  pupils  sluggish;  photophobia;  sensory  reflex  absent. 
Chorio-retinitis ;  arteriosclerosis. 

Veins ;  antony. 

The  following  report  is  extracted  from  "Pellagra,"  by  Prof.  A. 
Marie,  of  Paris.  Prefaced  by  Prof.  Lombroso.  Authorized  transla- 
tion from  the  French  by  C,  H.  Lavinder,  M.  D.,  U.  S.  P.  H.  and 
M.  H.  service,  and  J.  W.  Babcock,  M.  D.,  Physician  and  Superin- 
tendent State  Hospital  for  the  Insane,  Columbia,  S.  C. 

Eye  Symptoms — Remarkable  peculiarities  are  found  in  the  eyes  of 
the  pellagrous ;  a  falling  of  the  supercilliary  fold  is  very  frequent  (28 
times).  In  many  cases  is  found  also  a  marked  unilateral  injection 
of  the  conjunctivae.  These  are  observations  which  remind  one  of 
general  paresis,  and  show,  along  with  other  manifestations,  how  fre- 
quently the  lesions  of  the  nervous  system  may  be  unilateral,  especially 
lesions  of  the  sympathetic  system. 

Very  often  also  (74  cases)  mydriasis  of  the  two  sides  is  found. 
Miosis  is  more  rare,  and  when  found  is  more  usual  in  the  aged. 
Cases  of  blepharitis  are  not  rare,  as  was  shown  by  the  Piedmont 
commission.  Often  also  diplopia,  photophobia  and  synchysis  are 
found.  Many  pellagrins  remain  for  years  with  their  eyes  closed  for 
fear  of  the  light.    Early  cataracts  are  found  among  the  pellagrous ; 


282 

aiid  pterygium  is  not  infrequent.  Dr.  Ottolenghi,  with  Professor 
Manfredi  and  Dr.  Flarer,  have  made  ophthalmic  studies  on  pella- 
grins.   Their  results  are  given  in  the  following  table : 

Number  examined 36 

Depth  of  eye  normal 12 

Changes  in  the  retina 15 

Atrophy  of  arteries 12 

Anomalies  in  fundus  of  left  eye i 

Anomalies  in  fundus  of  right  eye 6 

Atrophy  of  optic  nerve 3 

Increase  of  pigment 3 

Dilatation  of  the  veins i 

Fifteen  of  these  cases  showed  retinal  changes  by  a  yellow  or  gray 
reflex  in  one  or  both  eyes — a  sign  of  precocious  senility ;  it  is  of  inter- 
est to  note  that  there  were  three  cases  of  white  atrophy  of  the 
papillae,  among  which  was  one  case  of  retine-choroiditis  in  an  ad- 
vanced stage.  Ottolenghi  found  also  in  three  pellagrins  one  light 
case  of  papillitis,  more  pronounced  in  the  left  eye;  in  the  second 
case  pronounced  gray  atrophy  and  diffuse  retine-choroiditis  of  the 
two  sides ;  the  third  was  normal.  It  is  of  interest  to  note  the  obser- 
vation that  in  several  individuals  the  ocular  fundus  differed  on  the 
two  sides.  -  This,  however,  cannot  be  given  as  a  reason  for  the  numer- 
ous pupilary  inequalities,  since  these  are  noted  in  individuals  who 
show  a  normal  fundus.  However,  the  unilateral  anomalies  of  the 
fundus,  as  well  as  those  of  the  pupils,  predominate  in  the  right  eye 
and  consist  in  lesions  of  the  arterial  vessels  with  papillary  and 
retinal  changes.  Rampoldi  observed  pellagrous  ocular  troubles  prin- 
cipally in  the  autumn  or  the  spring,  and  found  that  they  consisted  of 
organic  lesions  rather  than  functional  disorders.  The  retina  and 
optic  nerve  show  more  than  any  other  part  of  the  eye  the  pellagrous 
cachexia,  next  come  the  cornea  and  lens ;  finally  the  choroid  and 
vitreous  body.  Hemperalopia  and  pigmentary  retinitis  are  not  rare. 
Torpid  ulcers  of  the  cornea  are  found  with  essential  hypotonus  of  the 
bulb  and  scintillating  synchosis  of  the  vitreous." 

The  numerous  pupil  inequalities  in  the  above  report  are  probably 
due  to  trophic  disturbances,  and  this  will  also  account  for  the  slow 
reaction  of  the  iris  to  drugs  that  are  dependent  upon  the  local  nerve 
endings.  We  must  also  take  into  consideration  that  this  report  does 
not  mention  the  number  of  cases  examined  when  seventy-four  dila- 


283 

tations  were  reported,  and  consequently  we  cannot  formulate  any  per- 
centage as  to  these  findings.  It  seems  that  the  thirty-nine  cases 
examined  by  opthalmologists  were  only  considered  from  the  an- 
omalies and  abnormalities  in  the  interior  of  the  eye.  The  pupilary 
reaction  and  external  eye  diseases  were  not  sufficiently  prominent 
or  intentionally  not  reported. 

Two  additional  cases  reported  to  me  by  Dr.  E.  N.  Carpenter,  one 
with  atrophy  and  one  complaining  of  a  continuous  green  light  before 
the  eye.  E.  M.  WHALEY. 

We  are  looking  for  light,  and  I  hope  this  will  stimulate  research 
and  assist  in  further  investigation. 


X 


284 


COMMENTS   ON  TWENTY-ONE  CASES  OF  PELLAGRA 

WILLIAM  F.  DREWRY,  M.  D. 
Superintendent  Central   State  Hospital 

PETEESBUEG,   VA. 

The  first  case  diagnosed  as  pellagra  in  this  institution,  and  I 
believe  the  first  in  Vir;jinia,  was  in  September,  1908.  Dr.  Rea 
Parker,  then  one  of  our  assistants,  first  observed  it.  Since  then 
twenty  other  cases  have  been  observed  and  studied  here.  In  addi- 
tion to  these  about  a  dozen  cases  have  been  seen  and  reported  by 
physicians  in  various  sections  of  the  State. 

Of  the  cases  occurring  at  this  hospital  all  were  negroes — 16 
black  or  brown  and  5  mulattoes.  Age  of  youngest  at  time  of  onset 
of  disease,  or  rather  full  development,  was  20,  oldest  60;  average 
35.  Nine  were  under  30,  only  3  over  40.  Ten  were  residents  of 
towns  or  cities;  11  lived  in  the  country.  Their  homes  were  not 
confined  to  any  particularly  geographical  section  of  the  State. 
With  three  or  four  exceptions  all  were  poor  and  illiterate.  Some 
had  fairly  comfortable  homes  and  lived  regular,  industrious  lives. 
Three  or  four  and  probably  others,  were  dissipated,  or  habitually 
immoral,  and  in  as  many  more  there  were  indications  of  syphilis 
and  in  a  majority  there  were  symptoms  indicating  tuberculosis.  One 
has  had  epilepsy  for  years.  In  one  of  those  of  the  better-to-do  class 
corn  was  seldom  if  ever  used  as  a  part  of  the  diet.  In  all  the  rest 
corn  doubtless  constituted  an  important  item  of  food.  In  those 
living  in  towns  or  cities  the  meal  was  doubtless  a  Western  product, 
and  the  same  thing  probably  applies,  in  a  large  measure,  to  those 
from  the  country  districts.  In  this  connection  I  may  be  pardoned 
for  saying  that  the  diet  at  the  hospital  is  wholesome,  nutritious  and 
ample,  and  while  much  of  the  corn  meal  used  is  a  Western  product 
it  has  seemed  to  be  of  excellent  quality. 

Eleven  of  the  cases  have  been  received  into  the  hospital  within  the 
past  fourteen  months  and  the  symptoms  existed  at  the  time  of 
admission  or  developed  soon  afterwards.  The  others  (10)  had  been 
residents  of  the  hospital  from  a  year  and  a  half  to  ten  years,  and  in 
nearly  all  these  there  had  been  a  history  of  recurrent  diarrhoea  and 
progressive  mental  deterioration,  but  as  far  as  the  histories  show, 
no  cutaneous  manifestations  were  observed.  There  has  been  notable 
uniformity   in   the   chief   physical,   cutaneous   nervous   and   mental 


285 

symptoms.  Muscular  weakness,  emaciation,  anemia,  more  or  less 
incoordination,  uncertain  gait,  tremor,  slow  and  slurring  or  thick 
speech,  usually- mutism  in  the  advanced  stages,  headache,  back-ache, 
anorexia,  insomnia,  have  marked,  to  a  greater  or  less  degree,  every 
case.  The  sensory  abnormalities  and  the  disturbance  of  eye  and 
patella  reflexes  have  varied.  No  convulsions  except  in  one  case. 
No  paralysis.  There  has  been  variation  in  the  several  cases  as 
to  the  pulse,  temperature  and  respiration.  In  most  of  the  cases 
the  gastro-intestinal  symptoms  have  been  practically  similar,  there 
being  remissions  in  practically  all.  The  symmetrical  skin  lesions, 
too,  have  been  about  alike  in  all  cases,  simply  varying  in  degree 
or  extent.  In  some  the  lesions  did  not  exist  on  the  feet,  neck, 
face  or  elbows,  but  in  every  instance  the  hands  were  involved.  In 
only  one  or  two  cases  was  the  face  exempt.  Hypertrophy  of  the 
sebaceous  glands  over  the  nose  was  present  in  every  case. 

The  mental  symptoms  have  run  a  remarkably  uniform  course,  not 
conforming,  however,  to  any  recognized  classification  of  psychosis. 
The  symptom-complex  approaches  perhaps  a  toxic-exhaustion 
psychosis,  of  depressed  type,  terminating  in  more  or  less  dementia. 
In  all  our  cases  there  were  mental  apathy,  despondency,  emotional 
irritability,  stupidity,  disorientation,  defect  or  loss  of  memory,  con- 
fusion, disturbance  of  attention,  clouding  of  consciousness,  usually 
insomnia,  etc.  In  some  there  was  occasionally  motor  restlessness 
and  mental  excitement,  and  in  some  hallucinations  and  delirium  of 
a  terrifying  or  depressed  nature.  Depression,  confusion  and  finally 
aementia  or  dementia  have  been  notable  in  every  case.  In  all  the 
cases  the  mental  and  nervous  deterioration  was  more  rapid  or  pro- 
nounced after  the  gastro-intestinal  and  cutaneous  symptoms  set  in; 
and  on  the  other  hand,  when  these  improved  the  mental  condition 
usually  improved. 

As  to  the  termination  of  the  cases :  seven  died  during  the  full 
development  of  the  triad  of  symptoms,  in  a  state  of  physical 
collapse  and  mental  disintegration.  In  three  the  symptoms  have 
improved,  in  four  the  gastro-intestinal  and  skin  symptoms  have 
entirely  disappeared,  and  in  the  rest  these  symptoms  are  improving. 
There  has  been  no  very  material  change  in  the  mental  condition  of 
any  of  the  patients,  save  one  or  two.* 

Dr.  J.  C.  Bardin,  pathologist  and  bacteriologist  at  the  hospital, 
who  is  carefully  studying  this  phase  of  the  cases,  that  is,  pathologi- 


*By  January  1,  1910,  there  had  been  a  total  of  nine  deaths,  and  in  all  the  other 
cases  all  cutaneous  and  gastro-intestinal  symptoms  had  disappeared. 


286 

cal,  reports  that  the  blood  showed  a  slight  anaemia  in  every  case; 
in  some  cases  it  appeared  markedly  concentrated  and  poor  in  fluid, 
doubtless  due  to  the  depleting  diarrhoea.  The  leucocyte  counts  were 
generally  about  normal;  some  were  slightly  below  normal.  Differ- 
ential counts  have  been  repeatedly  made,  and  in  practically  every 
case  there  has  been  a  change  in  the  lymplocyte  and  eosinophiles 
content,  presenting  certain  features  apparently  constant  in  this 
affection.  Dr.  Bardin  is  not  yet  ready  to  announce  the  full  results 
of  his  observations,  as  they  have  not  yet  been  fully  worked  out. 
Mophologically  the  red  blood  cells  show  some  variation  from  the 
normal  size,  tending  to  be  larger  than  usual  and  in  some  cases 
poikilocytosis  and  polychromatophilia  were  observed.  There  were 
no  abnormal  leucocytes. 

The  blood  pressure  in  every  case  but  one  has  been  below  normal. 
In  one  case  it  averaged  about  i8o  m.m.  from  day  to  day,  while  the 
other  cases  averaged  about  112  m.m. 

The  urine  presents  nothing  abnormal,  save  a  diminution  fjtn 
chlorides  in  every  case. 

Post-mortem  examinations  in  four  cases  showed  the  following 
general  features :  In  three  cases  there  was  intestinal  tuberculosis ;  in 
two,  marked  pulmonary  tuberculosis ;  in  one,  old  healed  foci  in  the 
lungs  and  no  tubercular  lesions  in  the  gut;  and  in  one  there  was 
no  lung  involvement,  though  there  were  eight  annular  intestinal 
ulcers.  The  presence  of  some  form  of  tuberculosis  in  every  case  that 
came  to  post-mortem  is  interesting;  it  probably  is  a  terminal 
infection. 

The  heart  in  every  case  was  atrophic  and  fibrous.  Myocarditis 
was  a  marked  feature.  Microscopically,  the  atrophic  muscles  were 
in  every  case  pigmented,  the  pigments  being  situated  about  the 
nuclei — the  so-called  "brown-atrophy"  of  the  heart.  The  liver  in 
each  case  showed  an  irregular  capillary  congestion,  atrophy  and 
cloudy  swelling  of  the  parenchyma  and  pigmentation.  Fatty  degen- 
eration has  not  been  observed.  The  spleen  has  shown  nothing  save 
marked  congestion. 

The  intestines  showed  in  each  case  a  marked  atrophy.  The 
muscles  and  mucosa  showed  great  thinning  and  in  places  the  entire 
mucous  membrane  had  disappeared.  An  infiltration  of  the  submucosa 
with  eosinophiles  was  noted  in  two  cases.  There  was  in  every  case 
but  one  a  pigmentation  (golden  brown)  of  the  muscular  coat.  The 
kidneys  have  shown  irregular  congestion  and  slight  increase  in  con- 
nective tissue,  chiefly  marked  in  the  capsules  of  Bowman  and  in  the 


287 

medulla.  Arterio-sclerosis  has  been  marked  and  the  left  coronary- 
artery  has  shown  this  condition  to  an  extraordinary  degree  in  every 
case.  The  brains  and  cords  of  these  cases  have  been  sent  to  Dr. 
Simon  Flexner,  Rockefeller  Institute,  for  examination.  His  report 
has  not  yet  been  received. 

The  general  line  of  treatment  followed  has  consisted  in  special 
attention  to  the  dietary,  daily  baths,  personal  hygiene,  modified  rest 
and  out-door  life,  attention  to  the  gastro-intestinal  disturbance,  to- 
gether with  eliminants,  tonics,  arsenic,  &c. 


Presented  at  the  Conference  on  Pellagra  held  at  Columbia,  S.  C,  November  3rd 
and  4th,  1909. 


288 


PELLAGRA,  THE  CORN  CURSE 

J.  S.  DE  JARNET 
Superintendent  Western  State  Hospital 

STAUNTONj   VA.. 

I  offer  no  excuse  for  writing  this  article,  even  though  the  medical 
and  lay  presses  are  publishing  literature  on  this  subject  daily.  I 
believe  unless  the  most  drastic  steps  are  promptly  taken  to  stop  the 
consumption  of  diseased  Indian  corn  in  our  Virginia  corn-eating 
State,  we  will  suffer  the  most  terrible  curse  that  has  ever  befallen 
our  fair  land.  The  demon,  I  believe,  lurks  in  a  green  fungus,  and 
there  lies  our  danger. 

The  majority  of  lexicographers  give  pellagra,  as  derived  from  two 
words,  pellis,  meaning  skin,  and  agra,  a  seizure;  others  give  pelle, 
skin,  and  agra,  rough. 

The  synonyms  of  pellagra  are :  Italian  leprosy,  Lombardy  leprosy, 
Alpine  scurvy,  Asturian  rose,  Maladie  de  las  Teste,  Mai  de  la  Rosa, 
Mai  de  Sole,  Vernal  Insulation,  Hydro-mania,  and  Mai  de  Miserere, 
etc. 

DEFINITION. 

Pellagra  is  an  endemic  skin  and  spinal  disease  of  Southern 
Europe.  Now  found  in  Virginia  and  fifteen  other  States  of  the 
Union.  It  is  said  to  be  caused  by  eating  diseased  or  damaged  maize, 
also  dependent  upon  bad  hygienic  conditions  and  exposure  to  the 
sun.  It  is  marked  by  increasing  erythema  of  the  exposed  skin — 
worse  in  spring,  fading  away  in  winter. 

Exfoliation  of  the  skin,  weakness,  spinal  pain,  digestive  disturb- 
ance, brain  and  cord  lesions,  mental  depression,  great  emaciation  in 
last  stage,  marked  tendency  to  insanity,  immobile  expression,  and 
usually  little  or  no  fever. 

ETIOLOGY. 

The  eating  of  diseased  Indian  com  is  almost  universally  believed 
to  be  the  cause.  This  theory  is  ably  maintained  by  Lombroso  and 
Balardini  on  account  of  the  greenish  color  produced  by  the  fungus. 
This  was  called  the  verdet  theory.  Belmondo  believed  pellagra  to 
be  due  to  a  specific  organism.  The  disease  is  never  found  except 
among  a  corn-eating  population,  and,  in  Italy  and  France,  where 


289 

pellagra  is  prevalent,  it  increases  in  proportion  to  the  amount  of 

musty  corn  products  consumed. 

The  fungus  may  develop  before  the  harvest  if  a  wet  season,  espe- 
cially if  the  corn  is  late  and  does  not  have  time  to  ripen.  It  may 
attack  the  grain  at  any  stage,  in  the  field,  in  the  com  crib,  at  the 
mill,  before  and  after  grinding,  and  even  after  cooking,  if  left  for 
any  length  of  time.  The  fungus  will  grow  on  the  bread,  or  breakfast 
food,  etc. 

In  Southern  France  and  Northern  Italy,  where  a  week's  supply  of 
the  corn  meal  gruel  or  polenta  is  all  cooked  at  one  time,  the  fungus 
grows  rapidly.  These  countries  have  heretofore  been  the  most 
pellagrous  in  the  world.    The  disease  is  not  contagious  in  any  sense. 

HISTORY. 

Pellagra  has  been  known  since  about  1750,  and  has  been,  and  is, 
endemic  in  Southern  France  and  Northern  Italy.  From  1830  to  the 
present  time  it  has  been  thoroughly  studied  by  Strambio,  Brierre  de 
Boismont,  Baillarger,  Billod,  Sacchi,  Gintrac,  Lombroso  and  others. 
Mental  derangement  frequently  accompanies  the  disease.  According 
to  Billod,  three-fifths  of  the  insane  in  the  asylum  at  Astino  were 
pellagrins ;  in  Senarra  one-third,  and  the  same  proportion  in  Servolo 
at  Venice.  Assistant  Surgeon  Lavinder,  U.  S.  M.  H.  S.,  states  in 
his  able  article  on  pellagra,  in  1907  there  were  100,000  pellagrins  in 
Italy,  and  upwards  of  50,000  in  Roumania. 

-In  pellagrous  countries  about  10  per  cent,  of  pellagrins  are  in  hos- 
pitals for  the  insane.  Assuming  this  to  be  true  in  Virginia,  we  have 
thirteen  reported  by  Dr.  W.  F.  Drewry,  of  Petersburg,  Superin- 
tendent of  the  Central  State  Hospital  for  the  Insane;  four  in  the 
Western  State  Hospital  at  Staunton,  Va.  Total,  17.  Therefore  we 
would  be  justifiable  in  believing  we  have  about  170  pellagrins  now  in 
Virginia. 

SYMPTOMS. 

The  symptoms  of  pellagra  are  too  numerous  to  mention.  The 
most  prominent  are :  recurring  erythema  in  the  spring  on  parts 
exposed  to  the  sun,  subsiding  during  the  winter;  ravenous  appetite, 
sometimes  horror  of  food ;  diarrhoea,  usually  persistent ;  great 
psychomotor  retardation,  vertigo  feeling  of  heat  and  pain  along  the 
spine,  burning  of  skin,  slight  losses  of  consciousness,  extreme  apathy, 
indisposition  to  do  any  kind  of  work  or  take  exercise,  intense  debility, 
num-bness  of  lower  limbs,  staggering  gait,  upper  extremities  ataxic, 

19— p.  C. 


290 

lower  spastic,  hallucinations  of  sight  and  hearing,  mutism,  immova- 
ble attitude — according  to  Sandwith — the  "Smile  forgotten  face;" 
slowness  of  speech,  incoherence  of  ideas,  sad  delirium  and  a  fixed 
idea  of  despair,  stuperose  melancholia,  delusions  and  suicide  by 
drowning.  The  hydromania  is  so  fearful  that  one  cannot  conceive 
of  its  intensity.  Strambio  says :  "The  intense  heat  of  the  skin 
excites  not  only  directly  to  immersion  in  water,  but  also  gives  rise  to 
delusions  of  fire,  both  in  this  world  and  in  the  next,  and  the  miserable 
victims  plunge  into  the  water  to  extinguish  at  the  same  time  the  real 
and  the  imaginary  fire." 

Gintrac  states  in  traveling  through  pellagrous  districts  he  was 
informed  that  every  year  many  insane  pellagrins  are  found  drowned 
in  ponds.  Miss  Marion  Hamilton  Carter,  in  a  carefully  written  arti- 
cle, November  number  of  McClure's  Magazine,  most  graphically  de- 
scribes the  water-mania.  She  says :  "It  is  largely  through  the  burn- 
ing sensations  that  water  comes  to  exercise  a  peculiar  and  often  fatal 
fascination  for  pellagrins.  They  love  it — love  its  feel  on  their  bodies, 
its  flow,  its  shining  surface ;  hang  over  it  by  day  and  dream  of  it  by 
night."  But  with  the  fascination  of  delight  runs  the  fascination  of 
terror,  even  in  the  same  patients.  The  water  seems  to  call  them, 
to  hold  them  in  a  spell.  They  cannot  withdraw  their  gaze  from  it, 
but  look  into  its  depths  until  nausea  and  vertigo  come  on  and  they 
fall  into  it.  In  this  state,  and  stunned  by  the  shock,  they  drown. 
Some,  on  coming  to  a  water  course,  close  their  eyes  and  cling  to  the 
nearest  tree  until  the  vertigo  passes,  then  shamble  away  in  fright, 
only  to  be  seized  with  the  charm  of  the  next  stream  and  throw  them- 
selves bodily  into  it.  Through  all  the  disease  runs  the  black  thread 
of  misery." 

DIAGNOSIS. 

The  multitudinous  symptoms  mentioned  above  are  very  confusing, 
and  I  think  the  following  are  usually  sufficient  to  make  a  diagnosis : 

I.  The  symmetrical  erythematous  eruption  on  the  back  of  the 
bands  and  exposed  parts  to  the  actinic  rays  of  the  sun.  The  eruption 
is  first  very  red  and  the  skin  is  exquisitely  sensitive  to  the  sun's  rays, 
becoming  blistered  from  the  slightest  exposure.  Attendants  in  hos- 
pitals for  the  insane  have  been  discharged  when  their  patients  were 
found  with  these  blisters,  the  superintendents  believing  the  vesicles  to 
be  the  result  of  scald  while  bathing.  After  the  acute  stage  wears  off 
the  eruption  becomes  scaly  and  the  skin  rough  and  dirty  looking, 
with  whitish  lines  running  along  its  natural  folds. 


291 

2.  The  diarrhoea  is  more  or  less  constant,  and  has  a  pecuHar  odor, 
probably  caused  from  an  inflammatory  condition  of  the  entire  alimen- 
tary tract. 

3.  Anaemia,  immobile  expression,  shiny,  bright  eyes,  and  indisposi- 
tion to  take  exercise. 

4.  The  victims  are  usually  among  the  very  poorest  class,  who  live 
largely  on  corn  products.  Since  poverty  compels  them  to  buy  the 
cheapest,  they  usually  get  that  which  is  diseased.  "^ 

PATHOLOGY. 

Leptomeningitis  is  found  with  much  thickening,  and  even  the 
formation  of  osseous  plaques;  the  anterior  cornual  cells  of  the  cord 
are  pigmented  and  atrophied ;  postero-lateral  sclerosis  of  the  columns 
of  Goll  and  Burdach  in  the  upper  cord  levels ;  and  the  lower  portion 
of  the  crossed  pyramidal  tract  sharply  sclerosed.  The  increased 
symmetrical  vulnerability  of  the  skin,  spasticity  of  lower  limbs,  ver- 
tigo, etc.,  I  think  clearly  indicate  we  have  a  poison  which  attacks  the 
trophic  centres,  and  the  insanity  indicates  special  selection  of  the 
brain  cells.  The  nerve  and  brain  poisons  seem  to  have  a  peculiar 
selection  for  the  skin ;  we  see  it  in  the  gin  blossom  of  alcoholics,  in 
the  erythema  of  atropine  poisons,  and  in  the  papular-pustule  erup- 
tion of  bromide  of  potash,  and  in  food  poisons  causing  urticaria,  etc. 

PROGNOSIS. 

If  the  disease  is  treated  early,  recovery  is  said  to  be  easily  secured 
(Lavinder) ;  if  allowed  to  run  on  death  is  the  rule  in  a  few  years. 
Seventy-eight  per  cent,  of  cases  are  curable  when  treated  properly. 
Of  the  four  cases  I  report,  two  are  dead  and  the  remaining  two  will 
not  live  very  long,  in  all  probability. 

TREATMENT. 

The  treatment  is  to  stop  all  diet  of  corn  products,  breakfast  foods, 
meal,  etc.,  and  give  mixed  animal  and  vegetable  diet.  Tonics,  such 
as  arsenic,  quinine  phosphates  and  chalybeates  are  to  be  given ;  care- 
ful avoidance  of  exposure  to  the  sun,  and  soothing  lotions  to  the 
eruption.  Atoxyl  has  been  recently  recommended  (Lavinder).  A 
serum  treatment  has  also  been  suggested,  the  serum  to  be  gotten 
from  horses  which  have  recovered  from  "Blind  Staggers"  caused  by 
eating  diseased  corn.  The  only  scientific  treatment  of  the  disease  is 
prevention,  and  this  should  be  attained  by  educating  the  laity  in 


292 

regard  to  the  dangers  in  the  use  of  musty  corn  products.  All  millers 
who  are  found  grinding  musty  com,  and  storekeepers  selling  musty 
meal,  should  be  fined  and  imprisoned.  The  school  teachers  in  our 
State  should  be  instructed  to  teach  the  horrors  of  pellagra  and  its 
cause.  The  farmers  should  have  special  bulletins  sent  them  teaching 
the  best  methods  of  drying  their  corn,  when  to  cut  it,  how  to  shock 
it,  house  it,  shell  it,  send  it  to  mill,  and  keep  it  when  at  home.  No 
cold  corn  bread  should  be  used  as  food  for  man,  and  all  breakfast 
foods  made  from  com  should  be  carefully  examined  before  eaten, 
and  none  kept  over  after  becoming  damp.  Dampness  from  salt 
water  is  especially  favorable  to  the  growth  of  the  fungus. 

VIRGINIA  CASES. 

There  have  been  nineteen  cases  of  pellagra  reported  in  Virginia 
so  far  as  I  can  collect;  thirteen  by  Dr.  Wm.  F.  Drewry,  of  the  Cen- 
tral State  Hospital  for  the  Insane  at  Petersburg;  one  by  Dr.  J.  H. 
Hewett,  Lynnhaven,  Va. ;  one  by  Dr.  Smith,  of  Amherst,  Va.,  and 
four  by  the  writer  in  the  Western  State  Hospital  at  Staunton,  Va., 
Ten  per  cent,  of  the  pellagrins  being  in  hospitals,  as  I  said  before, 
we  have  about  170  now  in  the  State.  While  this  number  seems  small, 
the  possibility  and  probability  of  the  rapid  spread  of  this  horrible  dis- 
ease is  fearful  to  consider,  and  now  is  the  time  to  fight  it. 

I  know  of  nothing,  not  even  the  great  white  plague,  which  will 
compare  with  this  disease  should  it  once  get  possession  of  our  land. 
I  say  this  without  fear  of  being  accused  of  pellagraphobia. 

We  have  had  four  cases  of  well  defined  pellagra  in  this  hospital. 
One  male  from  Amherst  County,  who  died  in  1908,  and  his  disease 
was  not  recognized  until  after  reading  the  recent  discussions  on  the 
subject;  one  male  from  Halifax  County  died  in  1908,  the  disease  sus- 
pected at  the  time,  but  not  clearly  recognized  until  a  few  months  ago. 
We  have  now  two  female  patients  with  pellagra ;  one  has  been  in  the 
hospital  ten  years  and  developed  the  disease  during  last  spring.  She 
has  been  demenated  for  years.  She  originally  came  from  Louisa 
County.  We  received  during  this  month  one  female  from  Pittsyl- 
vania County,  near  Danville,  in  the  last  stages  of  the  disease.  All  of 
these  cases  came  from  among  the  poorest  classes  of  people  in  the 
State,  and  became  demented  rapidly.  There  was  nothing  unusual  in 
the  symptoms  of  these  pellagrins,  as  they  ran  the  usual  course.  We 
have  had  two  additional  suspects,  but  as  they  improved  so  rapidly  we 
sent  them  home  on  furlough  apparently  well.  We  will,  however, 
keep  in  touch  with  them.    One  was  a  woman  from  Alexandria  City, 


293 

jind  one  a  woman  from  Spottsylvania  County.  Why  we  have  never 
had  pellagra  here  in  the  United  States  before  is  a  natural  inquiry, 
this  being  the  home  of  the  maize.  I  believe  the  fungus  possibly  has 
been  comparatively  recently  imported  from  the  infested  districts, 
brought  in  in  the  food  of  Italian  immigrants,  and  would  recommend 
that  the  government  have  the  food  of  all  immigrants  examined  imme- 
diately on  arrival  from  pellagrous  countries. 


294 


A  CASE  OF  PELLAGRA  IN  ILLINOIS  OCCURRING  OUT- 
SIDE OF  AN  INSTITUTION 

GEORGE  W.  MITCHELL,  M.  D. 

First  Assistant  Physician,  Peoria  State  Hospital,  October,  1909. 

Patient  was  bom  in  Braunschweig,  Germany,  of  German  parents. 
Both  paternal  and  maternal  grandparents  were  healthy  individuals. 
The  paternal  grandfather  was  seventy  years  of  age  at  death.  Cause 
is  not  known.  The  father  of  the  patient  was  considered  a  healthy 
man  and  died  at  the  age  of  seventy-two.  Patient  states  that  there 
was  very  little  the  matter  with  him.  The  mother  suffered  an  acci- 
dent due  to  a  fall  and  died  a  few  years  later  at  the  age  of  sixty. 
There  were  four  brothers  on  the  father's  side,  one  brother  on  the 
mother's  side,  who  lived  to  an  old  age.  Patient  had  two  brothers 
and  four  sisters.  The  oldest  brother  lived  to  an  old  age,  the  younger 
brother  dying  from  complications  following  a  double  inguinal 
hernia.  One  sister  died  in  this  country  at  the  age  of  sixty-five  from 
''bleeding  of  the  lungs."  He  does  not  know  if  the  other  sisters  are 
living  or  not.  Emigrated  to  America  in  1857  to  Indiana  and  in 
1873  came  to  Central  Illinois.  Has  always  been  a  farmer  and  a 
hard  working  man.  Has  raised  and  handled  corn  during  his  active 
working  life  until  twelve  years  ago  he  moved  to  a  city  of  ten 
thousand  a  few  miles  from  his  farm.  Since  that  time  he  has  done 
the  work  about  his  residence  and  drove  back  and  forth  to  his  farm 
two  or  three  times  a  week.  Has  always  been  able  to  sleep  well  and 
at  present  sleeps  exceptionally  good,  going  to  bed  at  nine  and  arising 
at  six.  Never  sleeps  in  the  day  time.  His  appetite  has  always  been 
good.  He  eat  corn  bread  but  did  not  care  for  mush  or  hominy. 
While  living  on  the  farm  usually  eat  corn  in  some  form  several 
times  a  week,  during  the  fall  and  winter  months  but  not  in  the 
summer.  After  moving  to  town  he  eat  but  little  corn  and  the  last 
few  years  practically  none.  Has  been  married  forty  years,  his  wife 
at  present  being  sixty-six  years  of  age  and  is  a  well  preserved,  active 
lady  for  her  years.  Has  always  been  in  good  health  and  was  never 
sick  in  bed  and  does  not  look  her  age  by  fifteen  years.  She  was 
always  very  fond  of  all  forms  of  corn  product,  not  only  corn  bread, 
but  was  very  fond  of  mush  and  hominy  and  eat  a  great  deal  more 
corn  products  than  her  husband.     Her  memory  is  clear,  intellect 


295 

sharp  and  has  never  had  any  sort  of  skin  eruption,  vertigo,  sore 
mouth  or  chronic  diarrhoea.  Seven  children  were  born  to  their 
union.  The  first  one  is  alive,  in  good  health  and  is  thirty-nine  years 
of  age.  The  second,  third,  fourth  and  fifth  died  in  infancy.  The 
deaths  varied  from  three  to  seven  months  after  birth.  There  was  an 
attempt  to  raise  all  these  children  with  the  bottle  as  the  mother 
had  no  milk.  All  died  with  the  "summer  complaint."  The  sixth 
child  was  a  girl,  is  in  good  health,  married,  thirty-one  years  of  age, 
has  two  children,  a  boy  and  a  girl,  aged  five  and  three  respectively, 
both  apparently  bright  and  in  good  health.  The  son  has  two  boys, 
aged  nine  and  six  respectively.  Both  are  in  good  health  and  each 
carries  his  respective  grade  in  school.  The  seventh  child  was  born 
dead.  The  mother  was  at  this  time  forty-six  years  of  age.  The 
patient  does  not  remember  of  having  the  ordinary  diseases  of  child- 
hood. If  so  were  not  severe.  Thirty-three  years  ago  had  two 
attacks  of  malaria.  Six  years  ago  an  attack  of  "dysentery."  There 
was  some  blood  in  stools  and  the  patient  was  in  bed  for  a  few  days. 
This  occurred  during  the  summer  when  there  was  a  mild  epidemic  of 
diarrhoea.  Patient  says  he  has  had  some  looseness  of  bowels  each 
summer  for  several  years  but  this  summer  has  been  constipated. 
He  has  been  taking  cathartics  since  erythema  appeared  "to  get  the 
poison  out  of  his  system."  Otherwise  has  always  been  in  very  good 
health.  Patient  has  an  abundance  of  iron  gray  hair  and  presents 
the  characteristic  placid  facies  of  the  even-tempered  Germans  of  his 
class.  He  is  apparently  fairly  well  nourished  and  looks  much 
younger  than  his  age.  Patient  articulates  well  and  has  the  slow 
characteristic  speech  of  his  class.  Eyes  react  promptly  to  light  and 
accommodation.  No  paralysis  of  any  of  the  eye  muscles.  Consenual 
present  both  eyes.  The  sight  is  good.  Has  no  teeth.  No  inflamma- 
tion of  the  mouth  or  gums.  Tongue  clear,  quite  broad.  Hearing  is 
good.  Lungs  negative.  Respiration  eighteen.  Has  cup-shaped 
depression  over  lower  part  of  the  sternum  which  is  quite  marked. 
Heart  is  normal  in  size  and  position.  The  first  sound  is  rather  loud 
and  booming  in  character.  The  arteries  can  be  palpitated  but  are 
certainly  not  sclerosed  to  any  extent.  Pulse  is  fifty-four  in  reclining 
posture.  Blood  pressure  i6o  (Shepherd).  The  abdomen  is  smooth 
and  pliable  and  no  pain  on  pressure.  Spleen  not  palpable.  The  grip 
is  firm  and  there  is  no  paresis  of  any  of  the  muscles. 


296 

REFLEXES. 

Elbow  reacts  promptly.  Patellae  reacts  promptly.  Planter  reacts 
promptly.  Suggestion  of  a  Babinski  on  the  right  side.  Oppenheims 
phenomena  present  both  sides.  No  ankle  clonus  elicited.  No  achilles 
elicited.  Abdominal  diminished.  Pain  sense  in  general  slightly 
diminished.  Cremasteric  reacts  promptly.  Temperature  sense 
normal.  No  areas  of  anathesia.  No  pain  or  tenderness  over  the 
spine.  Romberg  negative.  Coordinates  well  in  every  way.  Axillary 
glands  enlarged  and  hard.  Otherwise  the  glandular  system  is  nega- 
tive. Temperature  normal.  Skin  lesions — erythema  on  exposed 
surface  of  the  neck,  with  very  fine  bran-like  desquammation,  par- 
ticularly pronounced  along  the  hair  margin  and  below  each  ear. 
Skin  dry,  parchment-like  to  touch  and  somewhat  thickened  and  in- 
durated. Involved  surface  behind  the  ear  began  with  erythema; 
there  was  an  irritating  and  itching  sensation  present,  vescicles  formed 
with  some  exudate  and  slight  hemorrhage  from  raw  surface  when 
denuded.  Patient  says  "skin  on  eye  lids  was  red  and  caused  some 
discomfort."  At  present  the  dorsum  of  right  hand  is  swollen,  skin 
dry,  harsh  to  the  touch,  thickened  and  somewhat  oedematous,  light 
red  in  color.  Entire  dorsum  surface  involved  extends  from  proximal 
phalangeal  joint  of  middle  ring  and  index  fingers  to  a  line  one  and 
one-half  inches  above  the  wrist  joint.  Entire  dorsum  of  thumb 
involved  and  line  of  demarcation  between  dorsal  and  palmar  sur- 
face extends  from  outer  margin  of  thumb  nail  running  upward  and 
inward  to  middle  of  wrist.  Anterior  surface  of  the  forearm  is 
involved  to  an  extent  of  two  and  one-half  inches  above  wrist  joint. 
Line  of  demarcation  on  forearm  abrupt  and  distinct.  The  most 
severe  involvement  is  over  the  dorsum  of  the  thumb,  the  radial  side 
of  the  dorsum  of  the  hands  and  the  radial  side  of  both  anterior 
and  posterior  involved  surface  of  forearm.  Over  this  sur- 
face everywhere  the  skin  shows  fissures,  very  dry  and  rough 
and  present  yellowish  squamae  which  are  at  present  quite  firmly 
attached.  Desquammation  is  proceeding.  Color  disappears  on 
pressure  with  exception  of  some  of  the  most  indurated  parts  where 
crustace  are  present.  Ulnar  side  of  dorsum  of  hand  and  involved 
portion  of  forearm  is  thickened,  dry  and  somewhat  harsh  to  the 
touch  but  does  not  present  the  severe  nature  of  the  radial  side. 
Ulnar  side  of  wrist  and  forearm  is  more  smooth  and  uninvolved. 
Left  hand  presents  an  involvement  symmetrical  with  the  right  both 
in  extent  and  degree  except  that  fissures  are  not  so  marked.  Gen- 
eral outline  does  not  differ  decidedly  anywhere  at  present.    There  is 


297 

a  dry,  thin  and  scaly  desquammation  of  extensor  surfaces  of  both 
arms  to  the  shoulder.  Skin  condition  first  appeared  about  six  weeks 
previous  as  a  slight  erythema  on  surface  of  radial  side  of  each  hand, 
gradually  extended  and  became  darker  in  color.  Was  washed  with 
soap  and  water  which  caused  the  skin  to  become  rough  and  cracked. 
Extensor  surface  of  an  arm  and  forearm  involved  at  same  time  as 
hands.  There  is  some  hypertrophy,  pigmentation  and  desquam- 
mation and  roughening  of  skin  over  both  heels,  and  outer  surface  of 
both  great  toe  joints.  Involved  surface  at  first  was  somewhat  painful 
to  the  touch  and  there  was  a  feeling  as  if  "little  worms"  were  crawl- 
ing about  under  the  skin.  This  was  very  annoying  to  the  patient 
and  would  disappear  at  times. 
Blood  Analysis : 

Haemoglobin  80  per  cent.  (Dare.) 

Erythrocytes  4,250,000. 

Leucocytes  count  11,600. 

Differential  count — negative. 

Color  Index. 

Urine  analysis  from  specimen  voided  at  mid-day : 

Specific  gravity  1016. 

Clear. 

Reaction  acid. 

No  albumen. 

No  sugar. 

No  acetone. 

No  peptone. 

Trace  of  Indican. 

Few  epithelial  cells. 

Cylinderoids  few. 

No  crystals. 


J/ 


t^-t 


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